Idiopathic Vocal Fold Paralysis Research Articles

Computed Tomography Measurements in Assessment of Idiopathic Vocal Fold Paralysis

Our study aimed to both identify the incidence and clinical presentation of patients presenting with idiopathic vocal fold paralysis (IVFP). Secondarily we aimed to assess the radiographic findings of computed tomography (CT) studies along the course of the vagus and recurrent laryngeal nerves (RLN), specifically measuring for potential areas of compression at the skull base and mediastinum. We hypothesized that a proportion of patients diagnosed with IVFP would have significant differences in measurements when compared to age-gender matched controls on CT imaging. Institutional review board approved retrospective cohort study METHODS: We assessed patients presenting to a tertiary voice care center between 2003 and 2019 with diagnosis of vocal fold paralysis. Data collected includes demographics, clinical exam findings, and CT measurements including dimensions at bilateral jugular foramen, aortopulmonary (AP) window and surrounding vascular structures. Statistical analysis was then performed using Pearson χ2, and Mann Whitney U tests to determine differences variables of interest. A total of 606 patients were reviewed. Of these patients 60 (9.9%) patients were determined to have IVFP. Left-sided VFP was seen more commonly in 78.3% (N=47) of idiopathic patients. Our IVFP group had an overall higher incidence of cardiovascular disease [OR=3.378, 95%CI 1.907-5.941, P < 0.001] compared to those with identified causes for paralysis. Specifically, IVFP patients showed a higher incidence of combined cardiovascular co-morbidities (P < 0.001), mitral valve stenosis (P=0.007), pulmonary hypertension (P < 0.0001) and congestive heart failure (P < 0.001). When evaluating CT imaging, the AP window was mentioned in only 2 (3.3%) of our idiopathic patients CT reports. The IVFP cohort had a lower median AP window volume (P=0.020) when compared to age-gender matched controls. This significantly smaller AP window volume was also seen when only left sided IVFP compared to both right-sided paralysis (P < 0.001) and age matched control patients (P < 0.001). The significance of cardiovascular comorbidities combined with findings of statistically narrowed AP window may help provide an explanation of a subset of patients diagnosed with IVFP.

A UNIQUE CASE OF BILATERAL VOCAL FOLD PARALYSIS FOLLOWING SPINAL ANAESTHESIA

Cranial nerve palsies are potential but rare complications of spinal anaesthesia. Most of the literatures support upper cranial nerve palsies like VI, IV and III cranial nerve palsies. Intrathecal hypotension resulting in tractional injury of the cranial nerves is the likely mechanism of injury. As on date, some cases of unilateral vocal fold paralysis and very little bilateral vocal fold paralysis have been described in case reports. We have described a patient who developed hoarseness and dysphagia 7 days after receiving spinal anaesthesia for fixation of inter-trochanteric fracture femur. The patient was diagnosed with bilateral vocal fold paralysis. He was managed conservatively and exhibited complete spontaneous recovery as has been described in the previously reported cases. Any patient presenting with idiopathic vocal fold paralysis should be enquired about the history of spinal or epidural anaesthesia. If the history is affirmative, then it points towards transient intrathecal hypotension as a potential etiology of the cranial nerve palsy.

A Clinical Audit of the Investigation and Follow-up of Vocal Fold Paralysis at Rigshospitalet, Denmark

Vocal fold paralysis (VFP) due to damage to the recurrent laryngeal nerves can be caused by malignant tumors. Therefore, thorough investigation, including diagnostic imaging, followed by follow-up examinations is acquired when assessing patients with VFP. Patients with VFP, with no immediate etiology found, are referred to Rigshospitalet, Denmark, where the investigation follows guidelines made by the Danish Society of Otorhinolaryngology, Head and Neck Surgery (DSOHH). The aim of this study is to examine whether or not the investigation of VFP at Rigshospitalet, Denmark, is in accordance with guidelines appointed by DSOHH. This study included 50 patients referred to Rigshospitalet, Denmark, in a one-year period between 2015 and 2016. Baseline data were collected from patient records and included sex, age, smoking history, side of paralysis, diagnosis and data regarding the initial investigation and any possible follow-up period. Of the 50 patients referred to Rigshospitalet, 15 (30.0%) were diagnosed with a malignant disease. Diagnostic imaging was not performed nor recommended to 3 (8.1%) patients. Fifteen (42.9%) patients did not receive a follow-up examination of whom a significant part had a malignant diagnosis. All patients with idiopathic VFP were offered a follow-up examination, but repeated diagnostic imaging was not performed in the cases without remission. Future assessments of patients with VFP should include diagnostic imaging of all patients and follow-up as recommended by DSOHH guidelines, focusing especially on patients with a malignant diagnosis and patients with sustained idiopathic VFP.

The incidence and recovery rate of idiopathic vocal fold paralysis: a population-based study.

To determine the incidence and spontaneous recovery rate of idiopathic vocal fold paralysis (IVFP) and paresis (IVFp), and the impact of steroid treatment on rates of recovery. This retrospective cohort study included all patients with IVFP or IVFp within a large integrated health-care system between January 1, 2008 and December 31, 2014. Patient demographics and clinical characteristics, including time to diagnosis, spontaneous recovery status, time to recovery, and treatment, were examined. A total of 264 patients were identified, 183 (69.3%) with IVFP and 81 (30.7%) with IVFp. Nearly all cases (96.6%) were unilateral and 89.8% of patients were over the age of 45. The combined (IVFP and IVFp) 7-year mean incidence was 1.04 cases per 100,000 persons each year with the highest 7-year mean annual incidence in white patients (1.60 per 100,000). The total rate of spontaneous recovery was 29.5%, where 21.2% had endoscopic evidence of resolution and 8.3% had clinical improvement in their voice without endoscopic confirmation. The median time to symptom resolution was 4.0months. Use of steroids was not linked with spontaneous recovery in multivariable analyses. The annual incidence of VFP (IVFP and IVFp) was 1.04 cases per 100,000 persons, with spontaneous recovery occurring in nearly a third of patients, regardless of steroid use.

Time Course of Recovery of Iatrogenic Vocal Fold Paralysis.

To clarify the time course of recovery in patients with iatrogenic vocal fold paralysis. Retrospective chart review. Medical records for all patients with iatrogenic vocal fold paralysis over a 10-year period were reviewed to obtain demographic and clinical information, including onset of disease and recovery of vocal function. Stroboscopic exams of patients who recovered voice were reviewed blindly to assess return of vocal fold motion. One hundred and two patients of 114 (89%) recovered vocal function. Time to recovery could be assessed in 39 patients who did not undergo injection augmentation. The mean time to recovery was 181.8 ± 109.3 days (left: 166.4 ± 106.7 days; right: 221.8 ± 115.6 days; P value = 0.095). Patients were analyzed according to anatomical site of surgery (skull base, carotid endarterectomy, thoracic, neck and intubation); there was no significant difference in time to recovery (P value = 0.60). Twelve of the 39 patients had recovery of vocal fold motion. The mean time to vocal recovery did not differ between patients with return of motion versus no return of motion (140.6 ± 118.0 days vs. 200.1 ± 102.2 days; P value = 0.147). Age, gender, laterality, and anatomical site of injury do not influence recovery rate in iatrogenic vocal fold paralysis. The probability of recovery decreases over time but more slowly in comparison with idiopathic vocal fold paralysis, reflecting the greater heterogeneity of injury type in the iatrogenic population. Commonly available aggregate recovery rates overstate the potential for recovery. 4 Laryngoscope, 129:1159-1163, 2019.

Time course of recovery of idiopathic vocal fold paralysis.

To clarify the time course of recovery in patients with idiopathic vocal fold paralysis. Retrospective chart review. Medical records for all patients with idiopathic vocal fold paralysis over a 10-year period were reviewed to obtain demographic and clinical information, including onset of disease and recovery of vocal function. Stroboscopic exams of patients who recovered voice were reviewed blindly to assess return of vocal fold motion. Thirty-eight of 55 patients (69%) recovered vocal function. Time course of recovery could be assessed in 34 patients who did not undergo injection augmentation. The mean time to recovery was 152.8 ± 109.3 days (left, 179.8 ± 111.3 days; right, 105.3 ± 93.7 days; P = .088). Two-thirds of patients recovered within 6 months. Probability of recovery declined over time. Five of 22 patients who recovered voice had return of vocal fold motion; 17 did not. The mean time to recovery did not differ between these groups (return of motion, 127.4 ± 132.3 days; no return of motion, 160.1 ± 105.1 days; P = .290). Sixty-nine percent of patients with idiopathic vocal fold paralysis recovered vocal function, two-thirds doing so within 6 months of onset. Age, gender, laterality, use of injection augmentation did not influence recovery rate. Declining probability of recovery over time leads us to consider framework surgery after 6 months in patients with idiopathic paralysis. 4. Laryngoscope, 128:148-152, 2018.

Aortic arch compliance and idiopathic unilateral vocal fold paralysis.

Unilateral vocal fold paralysis (UVP) occurs related to recurrent laryngeal nerve (RLN) impairment associated with impaired swallowing, voice production, and breathing functions. The majority of UVP cases occur subsequent to surgical intervention with approximately 12-42% having no known cause for the disease (i.e., idiopathic). Approximately two-thirds of those with UVP exhibit left-sided injury with the average onset at ≥50 yr of age in those diagnosed as idiopathic. Given the association between the RLN and the subclavian and aortic arch vessels, we hypothesized that changes in vascular tissues would result in increased aortic compliance in patients with idiopathic left-sided UVP compared with those without UVP. Gated MRI data enabled aortic arch diameter measures normalized to blood pressure across the cardiac cycles to derive aortic arch compliance. Compliance was compared between individuals with left-sided idiopathic UVP and age- and sex-matched normal controls. Three-way factorial ANOVA test showed that aortic arch compliance (P = 0.02) and aortic arch diameter change in one cardiac cycle (P = 0.04) are significantly higher in patients with idiopathic left-sided UVP compared with the controls. As previously demonstrated by other literature, our finding confirmed that compliance decreases with age (P < 0.0001) in both healthy individuals and patients with idiopathic UVP. Future studies will investigate parameters of aortic compliance change as a potential contributor to the onset of left-sided UVP.NEW & NOTEWORTHY Unilateral vocal fold paralysis results from impaired function of the recurrent laryngeal nerve (RLN) impacting breathing, swallowing, and voice production. A large proportion of adults suffering from this disorder have an idiopathic etiology (i.e., unknown cause). The current study determined that individuals diagnosed with left-sided idiopathic vocal fold paralysis exhibited significantly greater compliance than age- and sex-matched controls. These seminal findings suggest a link between aortic arch compliance levels and RLN function.

Predictors for Permanent Medialization Laryngoplasty in Unilateral Vocal Fold Paralysis.

Early differentiation of patients with unilateral vocal fold paralysis (VFP) who recover from those who do not and consequently require permanent medialization laryngoplasty (ML) remains a challenge. The goal of this study is to identify factors that predict the need for ML. Case series with chart review. Academic center. A total of 507 records of patients with VFP were analyzed, of which 252 met criteria and were stratified according to whether or not they obtained ML. Demographic information and clinical features were analyzed to determine predictors of ML. A nomogram was generated according to the significance and utility of these parameters. Of 252 patients, 86 underwent ML, and 166 did not. No differences in age or sex were observed between the ML and non-ML patients (P = .27 and P = .35, respectively). The most common cause of VFP was iatrogenic injury (62.79%, ML; 49.40%, non-ML). ML correlated with VFP secondary to neoplastic disease (odds ratio [OR], 2.14; 95% confidence interval [95% CI], 1.01-4.53) and iatrogenic injury (OR 1.73; 95% CI 1.01-2.94). ML had an inverse correlation with idiopathic VFP (OR, 0.40; 95% CI, 0.20-0.79). Patients in the ML group were more likely to have left-sided VFP, to have a history of aspiration, and to present ≥90 days from onset and less likely to have had temporary injection augmentation. Clinical features may be used to predict the likelihood of a patient obtaining ML. Nomograms may be useful to counsel patients who would benefit from early definitive surgery.

Recurrent Vocal Fold Paralysis and Parsonage-Turner Syndrome

Background. Parsonage-Turner syndrome, or neuralgic amyotrophy (NA), is an acute brachial plexus neuritis that typically presents with unilateral shoulder pain and amyotrophy but also can affect other peripheral nerves, including the recurrent laryngeal nerve. Idiopathic vocal fold paralysis (VFP) represents approximately 12% of the VFP cases and recurrence is extremely rare. Methods and Results. We report a man with isolated recurrent unilateral right VFP and a diagnosis of NA years before. Conclusions. We emphasize that shoulder pain and amyotrophy should be inquired in any patient suffering from inexplicable dysphonia, and Parsonage-Turner syndrome should be considered in the differential diagnosis of idiopathic VFP.

Recommendations on follow-up strategies for idiopathic vocal fold paralysis: evidence-based review

Vocal fold paralysis can be an early warning sign of serious extra-laryngeal pathology. Even if imaging investigations show no pathology, there is always concern about the emergence of new pathology in the future. There is currently no consensus on the best follow-up protocol for vocal fold paralysis patients with no abnormalities on investigation. Systematic review, using an Ovid and Medline database search of papers written in the English language and published in the last 20 years. Eight relevant studies were identified. Not all of them were directly comparable. A narrative review of the studies is presented and conclusions are drawn. Current diagnostic modalities are sufficiently reliable and sensitive to diagnose any significant existing extra-laryngeal pathology. Thus, once initial investigation (including computed tomography) has concluded, no further follow up is necessary.

Idiopathic vocal fold paralysis: Clinical course and outcomes

Idiopathic vocal fold paralysis: Clinical course and outcomes

Idiopathic vocal fold paralysis: Clinical course and outcomes

This investigation details the results of a retrospective chart review of 35 patients with idiopathic vocal fold paralysis. Clinical findings at presentation, as well as patient outcomes in both the short and long-term duration are comprehensively reported. Spontaneous improvement of vocal fold function was observed in 25% of patients with long-term follow up. Of those with unilateral paralysis, 27% elected to undergo surgical intervention for improvement of symptoms. Four out of the five (80%) patients with bilateral paralysis required surgical intervention, including tracheotomy to relieve severe dyspnea and stridor. Discussions regarding possible underlying, occult etiologies of idiopathic vocal fold paralysis are presented, and suggested sequential behavioral and surgical treatment strategies are introduced.

The Natural History of Idiopathic Unilateral Vocal Fold Paralysis: Evidence and Problems

To identify clinical evidence regarding outcome and duration of unilateral idiopathic vocal fold paralysis (IVFP). Literature review. Medline search using the terms "vocal fold paralysis," "laryngeal paralysis," "vagal paralysis," and "recurrent nerve paralysis" was performed. Results were cross-checked by substituting "palsy" and "paresis" in place of "paralysis," "cord" in place of "fold," and adding "idiopathic" to each term. Furthermore, papers antedating the period of time covered by Medline were identified in references of publications. Case series identified by means of these searches were examined for information regarding duration and outcome of IVFP. Seven hundred seventeen cases are reported. Complete recovery of motion occurred in 36 +/- 22% (range, 13-83%) of individuals. Some recovery of motion (complete and partial) occurred in 39 +/- 20% (range, 19-83%). Complete recovery of voice occurred in 52 +/- 17% (range, 25-87%) of cases, some degree of recovery in 61 +/- 22% (range, 25-87%). Most cases appear to recover in well under a year, with rare instances of markedly delayed recovery. Review of available evidence reveals a highly variable rate of return of motion in IVFP. The rate of return of normal voice is consistently higher, although similarly variable. The marked differences in rates of recovery among reports appears to be the result of variable definitions of recovery, oversimplified all-or-none notions of paralysis and recovery, and inconsistent reporting of time elapsed from onset of paralysis to evaluation. All of these factors should be addressed in future prospective studies to shed further light on the natural history of vocal fold paralysis.

Diagnostic Testing for Vocal Fold Paralysis: Survey of Practice and Evidence‐Based Medicine Review

Vocal fold paralysis continues to be a dominant topic in laryngology. Although the majority of cases can be attributed to a known etiology, a significant number of patients present without a clear precipitating event. Over 1,500 studies regarding vocal fold paralysis exist in the medical literature, although only a small percentage report on the use of serum or radiographic testing for the evaluation of idiopathic paralysis. Despite this, patients are routinely subjected to diagnostic evaluation to investigate the underlying cause. To characterize contemporary practice, a national survey of the American Broncho-Esophagological Association (ABEA) membership was undertaken. It is hypothesized that the current practice of diagnostic testing for idiopathic vocal fold paralysis is not well supported by an evidence-based medicine (EBM) review of the available medical literature. The authors conducted a national survey, systematic EBM review of existing literature. Surveys were mailed to all active ABEA members; responses regarding practice specialization as well as serum/radiographic diagnostic preferences for idiopathic vocal fold paralysis were tabulated and subjected to statistical analysis. To compare contemporary practice with evidence in the available literature, an EBM review was first performed. Articles for evaluation were selected from a Medline search of English-language abstracts related to adult vocal fold paralysis. The publications were individually reviewed and an EBM level and grade were assigned and compared with the survey results. Eighty-four of 249 active members responded with 76 (31%) replies submitted for analysis. Specific serum tests were advocated by 41 of 76 (54%) respondents, although the majority (52 of 65 [80%]) felt that they were only "occasionally" or "never" necessary. The most common tests were rheumatoid factor (38%), Lyme titer (36%), erythrocyte sedimentation rate (34%), and antinuclear antibody (33%). Fifty-one of 71(72%) felt that computed tomography (CT) was "always" or "often" necessary and 50 of 72 (69%) replied that chest radiography (CXR) was "always" or "often" necessary. There was no significant difference between CT and CXR ordering (P < .51). In contrast, magnetic resonance imaging (MRI) was described as "always" or "often" necessary in 28 of 71 (39%) of the surveys, significantly less than CT (P < .0001). There was no statistical impact of practice specialization on ordering of serum tests (P = .25) or imaging (P = .50 for CT; P = .46 for CXR; P = .45 for MRI). Following analysis of 1,510 vocal fold paralysis abstracts, 19 publications were found to be appropriate for an EBM review of serum testing with 15 available for review of radiographic imaging. Only one study presented level III evidence; the remainder were levels IV and V comprised of retrospective series and case reports. The evidence supporting serum or radiographic testing toward the evaluation of idiopathic vocal fold paralysis is given an overall grade of "C." Serum and radiographic testing for the evaluation of vocal fold paralysis is supported by grade "C" evidence only. There are no existing prospective studies estimating the clinical impact of testing on diagnosis or patient outcome. Current practice, as estimated by a survey of the ABEA membership, is not well founded for serum testing and only by retrospective case series with regard to imaging. Further study into the nature of idiopathic vocal fold paralysis and outcomes assessment of diagnostic paradigms may improve clinical practice.

Neuroimmunological activation of the afferent laryngeal neural circuit in experimentally induced laryngeal inflammation

ConclusionsThese results show that laryngeal inflammatory reactions may induce the expression of proinflammatory cytokines along the afferent laryngeal circuit and in nuclei associated with the HPA axis. Local laryngeal inflammation may induce functional and physiologic alterations in the laryngeal neural system via neuroimmunologic reactions.ObjectiveIdiopathic laryngeal disorders associated with various neurologic conditions such as spasmodic dysphonia, idiopathic vocal fold paralysis and sudden infant death syndrome are causally related to upper respiratory tract infections, and it can be speculated that these disorders result in neurophysiologic alterations. The goal of this study was to identify the neurophysiologic effect on the central nervous system of local inflammatory alterations in the larynx.Material and methodsThe expression of c-fos and IL-1β was identified after injecting saline solution, 10 μg of lipopolysaccharide or 100 μg of lipopolysaccharide into the larynx of 12 rats.ResultsThe inflammatory cytokine IL-1β was mainly expressed in the inferior olivary nucleus and raphe nucleus, which are associated with the hypothalamic–pituitary–adrenal (HPA) axis. IL-1β expression was also found in the nuclei of afferent nervous pathways of the superior laryngeal nerve, such as the nucleus tractus solitarius, nucleus ambiguus, lateral reticular nucleus, magnocellular reticular nucleus and paragigantocellular reticular nucleus.

Hoarseness Caused by Unilateral Vocal Fold Paralysis: How Long Should One Delay Phonosurgery?

We present a case of idiopathic right vocal fold paralysis which resolved completely 18 months after onset. Instead of using surgery to improve the hoarseness of our patient, our experience suggested that speech therapy might be effective. Although the voice can be improved by overadduction of the healthy vocal fold, as surgery is irreversible it is better to wait for 18 months after onset in case spontaneous recovery occurs. During this period, one should of course continue to investigate the origin of the paralysis.

Pediatric vocal fold paralysis: a long-term retrospective study.

To review our experience of pediatric vocal fold paralysis (VFP), with particular emphasis on etiological factors, associated airway pathologic conditions, and treatment and prognostic outcomes. Retrospective case review of a cohort of patients presenting with VFP. Tertiary referral center. A consecutive sample of 102 patients presenting with VFP to Great Ormond Street Hospital for Children, London, England, over a 14-year period from 1980 to 1994. There was an almost equal distribution of unilateral (52% [n = 53]) and bilateral (48% [n = 49]) VFP. Iatrogenic causes (43% [n = 44]) formed the largest group, followed by idiopathic VFP (35% [n = 36]), neurological causes (16% [n = 16]), and finally birth trauma (5% [n = 5]). Associated upper airway pathologic conditions were noted in 66% (n = 23) of patients who underwent tracheotomy. Tracheotomy was necessary in only 57% (n = 28) of children with bilateral VFP. Prognosis was variable depending upon the cause, with neurological VFP having the highest rate of recovery (71% [5/7]) and iatrogenic VFP the lowest rate (46% [12/26]). Recovery after an interval of up to 11 years was seen in idiopathic bilateral VFP; this has significant implications when considering lateralization procedures in these patients.

Vocal fold paralysis in infants twelve months of age and younger.

Seventeen cases of unilateral or bilateral vocal fold paralysis were diagnosed in infants younger than 12 months from 1991 to 1994 at the University of Iowa Hospitals and Clinics. Eight (47%) children with left vocal fold paralysis had a history of prior thoracic surgery--two to repair complex congenital anomalies and six to ligate a patent ductus arteriosus. During the study period, a total of 81 patent ductus arteriosus ligations were performed, yielding a 7.4% postoperative incidence of vocal fold paralysis. Seven (41%) children had idiopathic vocal fold paralysis (3 right, 1 left, 3 bilateral). Two (12%) children had VFP caused by central nervous system pathology (1 right, 1 bilateral). Tracheotomy was not required in any case. Prognosis for vocal fold paralysis varied with cause. With left vocal fold paralysis caused by thoracic surgery, no improvement was noted after an average follow-up of 6 months; with idiopathic vocal fold paralysis infants improved within an average of 6 weeks of diagnosis; with vocal fold paralysis caused by central nervous system pathology, treatment of the underlying condition was followed by return of vocal cord function. Irrespective of cause, the morbidity associated with vocal fold paralysis is minimal. Although tracheotomy is not required, careful airway observation is important. Differences and similarities of these results with other studies are discussed.

Vocal fold paralysis in infants twelve months of age and younger

Seventeen cases of unilateral or bilateral vocal fold paralysis were diagnosed in infants younger than 12 months from 1991 to 1994 at the University of Iowa Hospitals and Clinics. Eight (47%) children with left vocal fold paralysis had a history of prior thoracic surgery–two to repair complex congenital anomalies and six to ligate a patent ductus arteriosus. During the study period, a total of 81 patent ductus arteriosus ligations were performed, yielding a 7.4% postoperative incidence of vocal fold paralysis. Seven (41%) children had idiopathic vocal fold paralysis (3 right, 1 left, 3 bilateral). Two (12%) children had VFP caused by central nervous system pathology (1 right, 1 bilateral). Tracheotomy was not required in any case. Prognosis for vocal fold paralysis varied with cause. With left vocal fold paralysis caused by thoracic surgery, no improvement was noted after an average follow-up of 6 months; with idiopathic vocal fold paralysis infants improved within an average of 6 weeks of diagnosis; with vocal fold paralysis caused by central nervous system pathology, treatment of the underlying condition was followed by return of vocal cord function. Irrespective of cause, the morbidity associated with vocal fold paralysis is minimal. Although tracheotomy is not required, careful airway observation is important. Differences and similarities of these results with other studies are discussed. (Otolaryngol Head Neck Surg 1996;114:18-21.)

Acyclovir for the Treatment of Idiopathic Vocal Fold Paralysis

Acyclovir for the Treatment of Idiopathic Vocal Fold Paralysis