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Unilateral Vocal Cord Paralysis Nora Malaisrie, M.D. Faculty Discussant: Natasha Mirza, M.D. Thursday, July 24, 2008 Otorhinolaryngology: Head and Neck.

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Presentation on theme: "Unilateral Vocal Cord Paralysis Nora Malaisrie, M.D. Faculty Discussant: Natasha Mirza, M.D. Thursday, July 24, 2008 Otorhinolaryngology: Head and Neck."— Presentation transcript:

1 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

2 Introduction Affects quality of life Affects quality of life Potential morbidity and mortality Potential morbidity and mortality A sign of a disease process with multiple etiologies, necessitating thorough evaluation A sign of a disease process with multiple etiologies, necessitating thorough evaluation Multiple therapeutic options that must be tailored to the patient Multiple therapeutic options that must be tailored to the patient

3 Anatomy Upper motor neurons from cerebral cortex to nucleus ambiguus in the medulla 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 Lower motor neurons from nucleus ambiguus exit the medulla as the vagus nerve Vagus nerve exits the skull base via the jugular foramen Vagus nerve exits the skull base via the jugular foramen Branches Branches –Pharyngeal branch –Superior laryngeal nerve –Recurrent laryngeal nerve

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

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

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

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

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

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

10 Etiology: Traumatic Iatrogenic: Surgical Iatrogenic: Surgical –Thyroidectomy –Anterior cervical spine procedures –Esophagectomy –Thymectomy –Carotid endarterectomy –Cardiothoracic surgery Aortic surgery Aortic surgery Coronary artery bypass grafting Coronary artery bypass grafting Pulmonary lobar resection Pulmonary lobar resection Mediastinoscopy Mediastinoscopy Iatrogenic: Non-surgical Iatrogenic: Non-surgical –Endotracheal intubation Arytenoid dislocation, subluxation Tapia’s syndrome –Nasogastric tube placement 1 Non-iatrogenic 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.

11 Etiology: Idiopathic Not well understood Not well understood Possible infectious cause Possible infectious cause –Lyme disease –Tertiary syphilis –Epstein-Barr virus –Herpes simplex virus Type I Diagnosis of exclusion 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 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 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 Rosenthal et al. showed that surgical causes of unilateral vocal cord immobility were the result of 1.Non-thyroid surgeries (67%) Anterior cervical spine (15%) Anterior cervical spine (15%) Carotid endarterectomy (11%) Carotid endarterectomy (11%) Cardiac (9%) Cardiac (9%) 2.Thyroid surgeries (33%) Thyroid (26%) Thyroid (26%) Parathyroid (6%) Parathyroid (6%) Thyroid and parathyroid (1%) 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 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. 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 Symptoms –Voice changes Hoarseness to aphonia Hoarseness to aphonia Compensatory voice changes Compensatory voice changes Vocal fatigue, neck pain Vocal fatigue, neck pain –Aspiration –Weak, ineffective cough Past medical and surgical history Past medical and surgical history Social history Social history

17 Evaluation – Physical Exam Cranial nerve exam Cranial nerve exam Nasopharyngolaryngoscopy Nasopharyngolaryngoscopy –Vocal cord asymmetry –Horizontal and vertical position –Glottic gap –Poooled secretions –Aspiration –Maximal phonation time (MPT) –Supraglottic hyperfunction

18 Evaluation – Physical Exam Videostroboscopy 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 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, ANA 1 Routine labs not supported by the literature if cause unknown. 2,3 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 Assess swallow function and aspiration –Modified barium swallow –Functional endoscopic evaluation of swallowing (FEES) No additional work up required if clear cut etiology No additional work up required if clear cut etiology

22 Evaluation – Imaging Modalities 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 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 Needle electrode placement into thyroarytenoid and cricothyoid muscle Assess Assess –Muscle at rest –Voluntary motor unit recruitment May not be useful in diagnosis May not be useful in diagnosis 1.Munin et al. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am. 2000 Aug;33(4):759-70. 2.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 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 fibrillations 2 Wang et al. reported that LEMG obtained 2-6 mo from onset have a sensitivity and PPV of 93% and accuracy of 87%. 2 Wang et al. reported that LEMG obtained 2-6 mo from onset have a sensitivity and PPV of 93% and accuracy of 87%. 2 1.Munin et al. Laryngeal electromyography: diagnostic and prognostic applications. Otolaryngol Clin North Am. 2000 Aug;33(4):759-70. 2.Koufman et al. Diagnostic laryngeal electromyography: The Wake Forest experience 1995-1999. Otolaryngol Head Neck Surg. 2001 Jun;124(6):603-6. 3.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 Cricoarytenoid fixation –Caused by Joint subluxation/dislocation with ankylosis Joint subluxation/dislocation with ankylosis Joint fixation by rheumatoid arthritis or gout Joint fixation by rheumatoid arthritis or gout –Normal EMG –Direct laryngoscopy Laryngeal malignancy Laryngeal malignancy

26 Treatment Goal: Improve voice and prevent aspiration. Patient factors affect treatment strategies. 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: Strategies: –Observation for 6-12 months –Speech and swallow therapy –Surgical intervention Temporary: Vocal fold injection Temporary: Vocal fold injection Permanent: Vocal fold injection with durable material, medialization thyroplasty +/- arytenoid adduction or laryngeal reinnervation Permanent: Vocal fold injection with durable material, medialization thyroplasty +/- arytenoid adduction or laryngeal reinnervation

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

28 Treatment – Injection laryngoplasty Injection with temporary materials temporizes the voice until return of function Injection with temporary materials temporizes the voice until return of function Many materials available for augmentation 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 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-injectionPost-injection

31 Treatment – Injection laryngoplasty Method: Under general anesthesia via direct laryngoscopy 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 Complications: Under- injection, over-injection, improper placement, foreign body reaction

32 Treatment – Medialization thyroplasty Direct medialization of the vocal cord Direct medialization of the vocal cord Performed alone or with arytenoid adduction or reinnervation procedure Performed alone or with arytenoid adduction or reinnervation procedure Implant material 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 Adv: Local anesthesia, voice feedback, reversible, vocal fold integrity preserved Disadv: Open procedure, technically difficult, closure of posterior gap limited Disadv: Open procedure, technically difficult, closure of posterior gap limited Complications: Penetration of laryngeal mucosa, infection, chondritis, implant migration, airway obstruction, undercorrection 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 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 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 Mucullough et al. showed that when combined with medialization thyroplasty, functional results exceeded the improvement attained with medialization alone. 2 1.Kraus et al. Arytenoid adduction as an adjunct to type I thyroplasty for unilateral vocal cord paralysis. Head Neck. 1999 Jan;21(1):52-9. 2.Mucullouch et al. Arytenoid adduction combined with Gore-Tex medialization thyroplasty. Laryngoscope. 2000 Aug;110(8):1306-11.

35 Treatment – MT + AA Complications of medialization thyroplasty with arytenoid adduction 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 Goal: Increase bulk and tone Indications: Poor chance of spontaneous recovery Indications: Poor chance of spontaneous recovery Nerve characteristics Nerve characteristics –RLN –Ansa cervicalis Types Types –Neuromuscular pedicle –Nerve-nerve anastamosis May be combined with temporary injection laryngoplasty until reinnervation May be combined with temporary injection laryngoplasty until reinnervation

37 Treatment – Laryngeal Reinnervation Nerve muscle pedicle (NMP) 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 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 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 Lorenz et al. reported improved vocal quality as well as glottic closure and vocal fold edge straightening. 2 1.Crumley. Update: ansa cervicalis to recurrent laryngeal nerve anastomosis for unilateral laryngeal paralysis. Laryngoscope. 1991 Apr;101(4 Pt 1):384-388. 2.Lorenz et al. Ansa cervicalis-to-recurrent laryngeal nerve anastomosis for unilateral vocal fold paralysis: experience 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 Unilateral vocal cord paralysis affects quality of life and may cause significant morbidity Thorough evaluation is mandatory to determine etiology if initially unclear Thorough evaluation is mandatory to determine etiology if initially unclear Many treatment options are available which are tailored to patient Many treatment options are available which are tailored to patient

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

41 References Cummings: Otolaryngology: Head & Neck Surgery, 4th ed. Cummings: Otolaryngology: Head & Neck Surgery, 4th ed. Bailey: Head and Neck Surgery – Otolaryngology, 4 th ed. Bailey: Head and Neck Surgery – Otolaryngology, 4 th ed. Rubin et al. Vocal Fold Paresis and Paralysis. Otolaryngol Clin N Am. 2007 Oct; 40(5): 1109-1131. 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. 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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