Vocal fold paresis: a review of clinical presentation, differential diagnosis, and prognostic indicators

Vocal Fold Paresis and Voice Outcomes following Vocal Fold Mass Excision

OBJECTIVE

To correlate the surgical results of vocal fold mass excision with pre-operative existence of vocal fold paresis.

METHODS

Data were collected on 66 patients who underwent excision of benign vocal fold masses from 2015 to 2020. The pre- and post-operative strobovideolaryngoscopy (SVL) examinations for all patients included were evaluated blindly by three otolaryngologists using THE Voice-Vibratory Assessment with Laryngeal Imaging (VALI) Form for scar severity, mucosal wave, free edge contour, glottal closure, and phase closure. The success of mass excision surgery was determined based on the presence of the following criteria post-operatively: 1) improved mucosal wave motion 2) improved phase closure or glottic closure 3) improved free edge contour and 4) lack of worsening of vocal fold scar severity. Surgery was considered successful if 3 or 4 criteria were met, partially successful if 1 or 2 criteria were met, and unsuccessful if no criteria were met. The percent recruitment of the thyroarytenoid, posterior cricoarytenoid (PCA), and cricothyroid muscles were used evaluated the severity of paresis as mild (70-99% recruitment), moderate (40-60% recruitment), or severe (0-39% recruitment). VHI-10 scores were used as subjective measures of pre- and post-operative voice.

RESULTS

Sixty-six patients (26 male, 40 female) were included in this study, with a mean age of 37.25 ± 16.6 (range 18-78). Twelve patients had no evidence of VF paresis noted during the initial clinical evaluation; and 52 patients had paresis and had undergone laryngeal EMG. 81% of these patients had mild paresis, 12.8% had moderate paresis, and 5.8% had severe paresis. Based on pre- and post-operative strobovideolaryngoscopy, there was improvement in mucosal wave in 44.9% of cases, improvement of phase or glottic closure in 85.4% of cases, improved free edge contour in 95.5% of cases, and worsening of scar in 38.5% of cases. 39.6% of surgeries were fully successful, 33.3% of surgeries were partially successful, and 27.1% were not successful. There was a significant correlation between female gender and vocal fold paresis (P = 0.048). Paresis severity did not correlate with complete or partial surgical success (P = 0.956), pre-operative VHI-10 scores (P = 0.519), post-operative VHI-10 scores (P = 0.563), or strobovideolaryngoscopy parameters. Unilateral and bilateral paresis did not correlate with any other parameter of surgical success (P >0.05).

CONCLUSION

This study suggests that there is no correlation between pre-operative vocal fold paresis and voice outcomes after mass excision surgery, that the majority of mass excision surgeries (72.9%) are successful based on improvement in stroboscopic parameters, and that the proportion of patients with moderate and severe paresis is consistent across all laryngeal nerves.

Analysis of the Outcomes of Immediate Recurrent Laryngeal Nerve Reconstruction During Thyroid Surgery for Prevention of Vocal Fold Paralysis

BACKGROUND

Recurrent laryngeal nerve (RLN) injury and the resulting paralysis is the most common and known complication of thyroid surgery. Several surgical techniques, such as medialization thyroplasty with or without arytenoid adduction and injection laryngoplasty, have been developed to treat RLN injury, but these procedures have specific limitations and complications. In this study, we present the outcomes for our patients who underwent immediate RLN reconstruction during thyroid surgery by analyzing both subjective and objective outcomes.

METHODS

A retrospective study was conducted for patients who underwent total or subtotal thyroidectomy between May 2012 and March 2020. Among them, patients who underwent immediate RLN reconstruction due to unilateral RLN injury were followed for at least 12 months. The voice perceptual evaluation, acoustic analysis, voice range profile, and Voice Handicap Index (VHI) scores were obtained preoperatively, 1 month, 6 months, and 12 months after surgery.

RESULTS

Among the 11 patients, 6 patients (54.5%) underwent direct anastomosis, and 5 patients (45.5%) underwent nerve grafts using ansa cervicalis and great auricular nerve. The grade and breathiness in the GRBAS (grade, roughness, breathiness, asthenia, and strain) scale and jitter item showed significant improvement at 12 months postoperatively, and although not statistically significant, the rest of the items also tended to improve. The total, functional, and physical scores on VHI improved significantly at 12 months postoperatively. Moreover, when comparing the voice analysis of the direct anastomosis group and the nerve graft group, there was no significant difference between the groups in objective and subjective results.

CONCLUSION

Immediate RLN reconstruction demonstrated significant voice improvement postoperatively, and reconstructing the nerve immediately and combining follow-up treatment in the event of RLN injury will greatly help patients improve their long-term voice outcomes.

Ingredients in the Visual Perception of Hypomobile Vocal Fold Motion Impairment

OBJECTIVES

The clinical determination of vocal fold (VF) hypomobility based on laryngoscopy is subjective. Previous studies point to VF motion anomaly as the most commonly reported factor in the diagnosis of hypomobility. This study tested the hypotheses that VF angular velocities and angular range of motion (ROM) differ between the two VFs in cases of unilateral VF hypomobility.

STUDY DESIGN

Retrospective.

METHODS

Semi-automated analysis of laryngoscopic videos of 18 subjects diagnosed with unilateral VF hypomobility and 13 subjects with normal VF mobility was performed to quantify/compare the VF angular velocity and ROM between the two VFs during /i/-sniff and laugh.

RESULTS

In the hypomobile VF group, 7 out of 15 (47%) videos with /i/-sniff and 5 out of 8 (63%) with laugh had a statistically significant difference in the angular velocities between the VFs in either abduction or adduction. For VF ROM, 8 out of 15 (53%) /i/-sniff videos and 4 out of 8 (50%) with laughter had a statistically significant difference between VFs. In the group without the diagnosis of VF hypomobility, 9 out of 13 subjects (69%) had no difference in VF angular velocity and ROM during either /i/-sniff or laugh.

CONCLUSIONS

Differences in VF angular velocity or ROM are measurable in a substantial subset of subjects diagnosed with unilateral VF hypomobility. Clinicians' ability to gauge VF motion goes beyond what can be extracted from frame-by-frame analysis. Other visual cues, in addition to VF angular velocity and ROM, likely contribute to the perception of unilateral VF hypomobility.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:866-874, 2023.

Analysis of Risk Factors for Phonation Disorders after Thyroid Surgery

Phonation disorders after thyroidectomy are among the most common complications and occur as a result of recurrent laryngeal nerve (RLN) injury. The multivariate analysis of risk factors for phonation disorders after thyroidectomy was assessed. A group of 830 patients with 1500 RLNs at risk of injury during thyroidectomy were analyzed retrospectively. The impact of the method of RLN identification, age, sex, BMI, kind of thyroid surgery, pathology, surgeon’s experience and thyroid volume on vocal cord paralysis was analyzed. We found that the retrosternal goiter and the volume above 100 mL were the most important risk factors for both transient and permanent paralysis. Thyroid cancer had a statistically significant impact on the increase in permanent paralysis, while this indication had practically no impact on transient paralysis. Among patients over 65 years with obesity, the probability of transient complications approximately doubled, with no effect on the permanent paralysis. Men were approximately 1.7 times more likely to develop any type of phonation disorder. Secondary operations more than doubled the risk of transient and permanent vocal cord paralysis. Thyroidectomy with only visual RLN identification was associated with a risk of both transient and permanent vocal cord paralysis almost two times higher, compared to neuromonitoring.

Ipsilateral Vocal Cord Monitoring for Carotid Endarterectomy and Concurrent Contralateral Vocal Cord Paralysis: A Case Report

Vagus nerve injury may complicate carotid endarterectomy (CEA). The recurrent laryngeal nerve (RLN) branches from the vagus nerve, innervating the ipsilateral vocal cord. Vagus nerve injury can cause vocal cord dysfunction. Intraoperative vocal cord monitoring can detect vagus nerve injury during CEA. A patient with distorted neck anatomy from radiotherapy to treat oropharyngeal cancer and resultant right vocal cord paralysis required left CEA. Anticipating difficult neck dissection risking vagus nerve damage with associate RLN malfunction, we added vocal cord electromyography (EMG) to routine CEA electroencephalography (EEG). We recommend vocal cord EMG in anatomically complex CEA to avoid vagus nerve injury.

Vocal fold injection material does not preclude interpretation of laryngeal electromyography

INTRODUCTION/AIMS

Temporary vocal fold injection (VFI) is a common treatment for acute and subacute vocal fold paralysis (VFP). Laryngeal electromyography (LEMG) is useful for diagnosing neurogenic causes of VFP. This study evaluated whether the presence of VFI material prevents interpretation of LEMG in patients with acute and subacute VFP.

METHODS

Patients with acute and subacute unilateral VFP (onset ≤6 mo) who underwent temporary VFI within 3 mo preceding LEMG were evaluated. A matched control group that did not undergo VFI was also studied. The LEMG team (laryngologist and electromyographer) performed and interpreted LEMG using a pre-specified protocol, including qualitative and quantitative motor unit analysis.

RESULTS

Eighteen patients with VFI underwent LEMG successfully with interpretation of spontaneous activity and motor unit recruitment. Fourteen patients were seen in follow-up to determine accuracy of established LEMG prognosis. Seven of seven subjects with poor LEMG prognosis did not recover vocal fold motion. Five of seven subjects with fair LEMG prognosis recovered vocal fold motion. Findings were similar for the control group.

DISCUSSION

VFI augmentation material did not prevent interpretation of meaningful LEMG data in patients with acute and subacute VFP, and accurate prognoses of vocal fold motion recovery were established.

Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment

BACKGROUND

Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group.

METHODS

A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach.

RESULTS

Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery.

CONCLUSION

After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.

Vocal Cord Palsies Missed by Transcutaneous Laryngeal Ultrasound (TLUSG): Do They Experience Worse Outcomes?

INTRODUCTION

Transcutaneous laryngeal ultrasound (TLUSG) is an innovative, non-invasive tool in detecting post-thyroidectomy vocal cord palsy (VCP). However, TLUSG failed to detect about 6-15% laryngoscopic examination (LE)-confirmed VCP. It is unclear whether the outcome of patients with VCP missed by TLUSG [false negative (FN)] is different from those with VCP diagnosed by TLUSG [true positive (TP)]. Therefore, this study aimed to compare the clinical outcome and prognosis between patients with FN results and TP results.

METHODS

Over 46 months, all consecutive patients undergoing thyroidectomy or endocrine-related neck procedure were recruited. They underwent pre-operative and post-operative voice assessments on symptoms, voice-specific questionnaire [voice handicap index questionnaire (VHI-30)], TLUSG and LE. For patients with post-operative vocal cord palsy, reassessment LE would be arranged at second, fourth, sixth and twelfth months post-operatively until VCP recovered.

RESULTS

In total, 1196 patients, including 74 post-thyroidectomy VCP, were recruited. For those with assessable vocal cords (VC), 58 VCP were correctly diagnosed by TLUSG (TP) and 10 VCP were missed by TLUSG (FN). Sensitivity and specificity of detecting a VCP by TLUSG were 85.3% and 94.7%, respectively. VHI-30 score was significantly increased after operation in TP group [31 (range - 6-105), p < 0.001] but not in FN group [20 (14-99), p = 0.089]. Comparing to TP group, VCP recovered earlier (69 vs. 125 days, p < 0.001) and less patients suffered from permanent VCP in patients with FN results. (34.5% vs. 0.0%, p = 0.027).

CONCLUSION

The VCP missed by TLUSG had a milder course of disease. Early recovery of VC function and non-permanent palsy were expected.

The Prevalence of Dysphonia and Dysphagia in Patients with Vitamin D Deficiency

OBJECTIVE

To investigate the prevalence of phonatory and swallowing symptoms in patients with hypovitaminosis D.

METHODS/DESIGN

All patients presenting to the endocrinology clinic and investigated for vitamin D deficiency between January 2018 and April 2018 were asked to participate in this study. Demographic data included age, gender, allergy, and history of smoking. Patients filled Voice handicap Index (VHI-10) and Eating Assessment Tool (EAT-10).

RESULTS

A total of 136 consecutive subjects presenting to the endocrinology clinic for vitamin D testing were included: 60 with hypovitaminosis D and 76 with no hypovitaminosis D. The mean vitamin D level in the study group and controls was 13.25 ng/mL and 31.91 ng/mL, respectively. There was no significant difference in the mean score of VHI-10, nor in the mean score of EAT-10 in patients with hypovitaminosis D versus those with no hypovitaminosis D (P value >0.05).

CONCLUSION

There was no significant difference in the prevalence of phonatory and dysphagia symptoms using VHI-10 and EAT-10 questionnaires between subjects with hypovitaminosis D and those with normal serum vitamin D levels.

Vocal fold paresis: Medical specialists' opinions on standard diagnostics and laryngeal findings

PURPOSE

There is still no clear consensus on the diagnostic value of specific laryngeal findings in patients with suspected vocal fold paresis (VFP). The aim of the study was to establish expert opinion on criteria for the diagnosis of VFP in Europe.

METHODS

A cross-sectional survey using the questionnaire introduced by Wu and Sulica for US American experts was addressed to laryngeal experts in Germany, Austria, and Switzerland and in a second survey wave to members of the European Laryngological Society.

RESULTS

100 respondents returned survey 1 (response rate 47.2%). 26% worked at a university department. 28% regularly used laryngeal electromyography (LEMG). A pathologic test results in LEMG was considered to have the strongest positive predictive value for VFP (79 ± 23%), followed by a decreased vocal fold abduction (70 ± 29%), decreased vocal fold adduction (61 ± 34%), and atrophy of the hemilarynx (61 ± 31%). The multivariate analysis showed the predictive value of LEMG was estimated lower by respondents from non-university hospital (β = - 16.33; confidence interval (CI) = - 25.63 to - 7.02; p = 0.001) and higher in hospitals with higher frequency of VFP patients per months (β = 1.57; CI = - 0.98 to 2.16; p < 0.0001). 30 ELS members returned survey 2 (response rate, 8.4%). Their answers were not significantly different to survey 1.

CONCLUSIONS

The laryngology experts in Europe rely on LEMG for diagnosis of VFP like the US American experts, but paradoxically only a minority uses LEMG frequently. Next to LEMG, motion abnormities were considered to have the best predictive value for the diagnosis of VFP.

Comparison of Clinical Characteristics Between Patients With Different Causes of Vocal Cord Immobility

Objective

To analyze the clinical characteristics between neurogenic and non-neurogenic cause of vocal cord immobility (VCI).

Methods

The researchers retrospectively reviewed clinical data of patients who underwent laryngeal electromyography (LEMG). LEMG was performed in the bilateral cricothyroid and thyroarytenoid muscles. A total of 137 patients were enrolled from 2011 to 2016, and they were assigned to either the neurogenic or non-neurogenic VCI group, according to the LEMG results. The clinical characteristics were compared between the two groups and a subgroup analysis was done in the neurogenic group.

Results

Among the 137 subjects, 94 patients had nerve injury. There were no differences between the neurogenic and non-neurogenic group in terms of demographic data, underlying disease except cancer, and premorbid events. In general characteristics, cancer was significantly higher in the neurogenic group than non-neurogenic group (p=0.001). In the clinical findings, the impaired high pitched 'e' sound and aspiration symptoms were significantly higher in neurogenic group (p=0.039 for impaired high pitched 'e' sound; p=0.021 for aspiration symptoms), and sore throat was more common in the non-neurogenic group (p=0.014). In the subgroup analysis of neurogenic group, hoarseness was more common in recurrent laryngeal neuropathy group than superior laryngeal neuropathy group (p=0.018).

Conclusion

In patients with suspected vocal cord palsy, impaired high pitched 'e' sound and aspiration symptoms were more common in group with neurogenic cause of VCI. Hoarseness was more frequent in subjects with recurrent laryngeal neuropathy. Thorough clinical evaluation and LEMG are important to differentiate underlying cause of VCI.

A novel variation of the recurrent laryngeal nerve

BACKGROUND

Injury to the recurrent laryngeal nerve is one of the most severe complications of thyroid surgery. Several anatomic variations of the nerve increase the likelihood of iatrogenic damage.

CASE PRESENTATION

A 50-year-old woman was presented to our department with a nodule in the right thyroid lobe, and she reported no voice changes. She had no history of surgery or radiation to the head or neck. Fine-needle aspiration was recorded as papillary thyroid carcinoma. The preoperative laryngoscopy revealed left vocal cord paralysis. Right thyroid lobectomy was performed. A scarce course of the left recurrent laryngeal nerve was found during the operation that ascended along the medial edge of the superior thyroid pole and finally disappeared beneath the superior cornu of the thyroid cartilage without any tracheal, esophageal, or laryngeal branches. The patient was discharged on the third postoperative day with the diagnoses of papillary thyroid carcinoma and congenital left vocal cord paralysis.

CONCLUSIONS

The novel variation of the recurrent laryngeal nerve may challenge the current concept of the anatomy of the nerve. The vocal folds mobility should be examined routinely before surgery in patients undergoing thyroid operation.

Vocal fold paresis – a debilitating and underdiagnosed condition

Objectives:

To review the clinical signs of vocal fold paresis on laryngeal videostroboscopy, to quantify its impact on patients’ quality of life and to confirm the benefit of laryngeal electromyography in its diagnosis.

Methods:

Twenty-nine vocal fold paresis patients were referred for laryngeal electromyography. Voice Handicap Index 10 results were compared to 43 patients diagnosed with vocal fold paralysis. Laryngeal videostroboscopy analysis was conducted to determine side of paresis.

Results:

Blinded laryngeal electromyography confirmed vocal fold paresis in 92.6 per cent of cases, with vocal fold lag being the most common diagnostic sign. The laryngology team accurately predicted side of paresis in 76 per cent of cases. Total Voice Handicap Index 10 responses were not significantly different between vocal fold paralysis and vocal fold paresis groups (26.08 ± 0.21 and 22.93 ± 0.17, respectively).

Conclusion:

Vocal fold paresis has a significant impact on quality of life. This study shows that laryngeal electromyography is an important diagnostic tool. Patients with persisting dysphonia and apparently normal vocal fold movement, who fail to respond to appropriate speech therapy, should be investigated for a diagnosis of vocal fold paresis.