Summary
Objectives
Unilateral vocal fold paresis or paralysis (UVFP) is a condition for which radiographic
evaluation and laryngeal electromyography (LEMG) are valuable to evaluate severity
of injury and direct treatment plans. Despite extensive research involving findings
suggestive of UVFP with radiographic imaging, no study has attempted to determine
which findings suggestive of UVFP on imaging are clinically significant and suggest
a need for intervention. The purpose of this study was to evaluate whether the severity
of vocal fold paresis/paralysis affects the likelihood of encountering radiographic
findings suggestive of UVFP. We also aimed to determine which findings suggestive
of UVFP on imaging were clinically significant and were associated with surgical intervention.
Materials and methods
A retrospective chart review was conducted of patients who had been diagnosed with
unilateral vocal fold paresis or paralysis and had been evaluated by CT scan and/or
magnetic resonance imaging and laryngeal electromyography (EMG) between the dates
of January 1, 2017 and January 9, 2018. Fisher's exact testing with Monte Carlo Simulation
was utilized to determine statistical significance of identified relationships. Univariate
analysis was conducted to assess for individual relationships between imaging results
and the potential predictor variables. Chi square analysis was conducted with the
various categorical variables to assess for any potential relationships to imaging
results. Statistical significance was determined utilizing chi square analysis.
Results
After data collection, 130 patients were included in the study population. Of the
112 patients with documented MRI results, 17% had a reported imaging abnormality suggestive
of true vocal fold paresis or paralysis (VFP). Of the 71 patients with documented
CT Neck results, 15.4% had an abnormality potentially concerning for true VFP. The
average decrease in recruitment of the right and left SLN was 23.8% and 26.1%, respectively.
The average decrease in recruitment of the right and left RLN was 37.3% and 57.78%,
respectively. Seventy four percent of patients who exhibited abnormal MRI were found
to have isolated SLN weakness, and 21% of patients were found to have a combined SLN
and ipsilateral RLN weakness. In patients with abnormal CT scans 45% were found to
have isolated SLN weakness, and 35% were found to have a combined SLN and RLN weakness.
MRI imaging again failed to display any significant degree of paresis. However, abnormal
CT results displayed severe CN X paresis in 36.84% vs 1.96% in normal scans. The chance
of an abnormal MRI and CT result was 2.78 and 5.55 times greater, respectively, for
each increase in the degree of severity of CN X paresis. When looking at the ability
of imaging to predict the chance of a patient undergoing surgery, 34.8% of patients
with an abnormal MRI underwent surgery compared to just 14.61% of those with normal
scans. For CT scans, 35% of patients with an abnormal scan underwent surgery, compared
with only 15.69% with normal imaging. When pooled, over 33% of patients with any abnormal
imaging underwent a laryngeal procedure compared to 13% of patients with normal imaging.
Conclusions
There is a relationship between severity of vocal fold paresis found on laryngeal
EMG and likelihood of detection on imaging. While CT was more likely to find characteristics
of UVFP than MRI, patients who had an abnormal finding on either modality were more
likely to undergo surgical intervention. These findings highlight the importance of
early referral of patients with abnormal laryngeal imaging to an otolaryngologist
for evaluation and possible intervention.
Key Words
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REFERENCES
- Neurophysiology of vocal fold paralysis.Otolaryngol Clin North Am. 2004; 37: 1-23https://doi.org/10.1016/S0030-6665(03)00165-8
- Vocal fold immobility: a longitudinal analysis of etiology over 20 years.Laryngoscope. 2007; 117: 1864-1870https://doi.org/10.1097/MLG.0b013e3180de4d49
- Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review.Int J Clin Pract. 2009; 63: 624-629https://doi.org/10.1111/j.1742-1241.2008.01875.x
- Evidence-based practice: evaluation and management of unilateral vocal fold paralysis.Otolaryngol Clin North Am. 2012; 45: 1083-1108https://doi.org/10.1016/j.otc.2012.06.011
- Voice-related quality of life (V-RQOL) following type I thyroplasty for unilateral vocal fold paralysis.J Voice. 2000; 14: 378-386https://doi.org/10.1016/s0892-1997(00)80083-1
- Voice outcome following thyroplasty in patients with cancer-related vocal fold paralysis.Auris Nasus Larynx. 2001; 28: 315-321https://doi.org/10.1016/s0385-8146(01)00101-8
- Laryngeal reinnervation using ansa cervicalis for thyroid surgery-related unilateral vocal fold paralysis: a long-term outcome analysis of 237 cases.PLoS One. 2011; 6: e19128https://doi.org/10.1371/journal.pone.0019128
- Diagnostic testing for vocal fold paralysis: survey of practice and evidence-based medicine review.Laryngoscope. 2006; 116: 1539-1552https://doi.org/10.1097/01.mlg.0000234937.46306.c2
- Laboratory evaluation of vocal fold paralysis and paresis.J Voice. 2017; 31: 168-174https://doi.org/10.1016/j.jvoice.2016.07.022
- Laryngeal electromyography: clinical application.J Voice. 2010; 24: 228-234https://doi.org/10.1016/j.jvoice.2008.08.005
- Laryngeal electromyography for prognosis of vocal fold palsy: a meta-analysis.Laryngoscope. 2012; 122: 158-161https://doi.org/10.1002/lary.22354
- Recurrent laryngeal nerve paralysis: a laryngographic and computed tomographic study.Radiology. 1983; 148: 149-155https://doi.org/10.1148/radiology.148.1.6856825
- Atrophy of the posterior cricoarytenoid muscle as an indicator of recurrent laryngeal nerve palsy.AJNR Am J Neuroradiol. 1999; 20: 467-471
- Usefulness of laryngeal phonation CT in the diagnosis of vocal cord paralysis.AJR Am J Roentgenol. 2008; 190: 1376-1379https://doi.org/10.2214/ajr.07.2778
- Radiology findings in adult patients with vocal fold paralysis.Clin Radiol. 2006; 61: 863-867https://doi.org/10.1016/j.crad.2006.02.016
- Using CT to localize side and level of vocal cord paralysis.AJR Am J Roentgenol. 2003; 180: 1165-1170https://doi.org/10.2214/ajr.180.4.1801165
- Echo-planar magnetic resonance imaging of deglutitive vocal fold closure: normal and pathologic patterns of displacement.Laryngoscope. 1996; 106: 568-572https://doi.org/10.1097/00005537-199605000-00009
- Feasibility of vocal fold abduction and adduction assessment using cine-MRI.Eur Radiol. 2017; 27: 598-606https://doi.org/10.1007/s00330-016-4341-3
- Laryngeal Electromyography. Third Edition. Plural Publishing, San Diego, CA2017
- Laryngeal Electromyography.3rd ed. Plural Publishing, San Diego, CA2017
- Vocal fold paresis: incidence, and the relationship between voice handicap index and laryngeal EMG findings.J Voice. 2019; 33: 940-944https://doi.org/10.1016/j.jvoice.2018.05.008
- Usefulness of computed tomography in the etiologic evaluation of adult unilateral vocal fold paralysis.World J Surg. 2013; 37: 1236-1240https://doi.org/10.1007/s00268-013-1991-z
- Prospective study to assess vocal cord palsy investigations.Otolaryngol Head Neck Surg. 2008; 138: 788-790https://doi.org/10.1016/j.otohns.2008.03.004
- Evaluation of unilateral vocal fold immobility.Curr Otorhinolaryngol Rep. 2014; 2: 105-113https://doi.org/10.1007/s40136-014-0043-z
- Unilateral vocal fold paralysis: causes, options and outcomes.Aust N Z J Surg. 1999; 69: 509-513https://doi.org/10.1046/j.1440-1622.1999.01613.x
- Chronic vocal cord palsy in Thuringia, Germany: a population-based study on epidemiology and outcome.Eur Arch Otorhinolaryngol. 2014; 271: 329-335https://doi.org/10.1007/s00405-013-2655-1
- Diagnostic yield of computed tomography in the evaluation of idiopathic vocal fold paresis.Otolaryngol Head Neck Surg. 2015; 153: 414-419https://doi.org/10.1177/0194599815593268
Article info
Publication history
Published online: February 10, 2023
Accepted:
January 17,
2023
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2023 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
