HSC Section 6 Nov2016 Green Book

Otolaryngology–Head and Neck Surgery 153(3)

Table 1. Demographic Data of IUVFP by Workup Groups: CT and Non-CT. a

Table 3. Videostroboscopic Findings of Paresis Subjects Included in this Study.

CT

Non-CT

Examination Feature

n (%)

Total unilateral paresis

174

63

Asymmetry of velocity of movement

138 (79) 129 (74) 117 (67) 91 (66) 72 (41) 65 (37) 45 (26) 26 (15) 17 (12)

Age, y b Women

54.5 (21-82)

53.9 (18-75)

Increased glottic show

98 (56) 88 (51)

33 (52) 33 (52)

Asymmetry of range of movement

Left laterality

Phase asymmetry

Supraglottic hyperfunction

Abbreviations: CT, computed tomography; IUVFP, idiopathic unilateral vocal fold paresis. a Results presented as n (%), except where noted otherwise. b Mean (range).

Incomplete closure

Bowing/atrophy of vocal fold

Deviation

Increased vibratory amplitude

Table 2. Symptoms of Paresis Subjects Included in this Study.

Symptom

n (%)

parathyroid adenoma that, on removal, was seen to be stretching the recurrent laryngeal nerve. A final case was due to an undiagnosed Arnold Chiari II malformation with tentorium crowding and tonsillar herniation. This patient was referred to neurosurgery and underwent urgent posterior fossa decompression. It is interesting to note that there were no other neurologic symptoms or signs nor evidence of bilateral paresis. In all of the above 3 benign cases under- going surgery, there was no recovery of function of the nerve after surgical intervention. The diagnostic yield equates to a number needed to treat of 34. In other words, to find 1 patient with a vocal fold paresis-associated lesion, 34 patients had to undergo CT. In contrast, 48 of 174 patients had a new incidental finding on CT that required further management. Further management was defined as serial clinical examination, repeat imaging, a diagnostic procedure, or operation. This equates to an inciden- tal yield of 27.6% (95% confidence interval, 23.7% to 37.8%). Of these 48 patients, 40 underwent clinical and or serial imaging follow-up alone; 5 underwent fine-needle aspiration alone; and 3 underwent surgery. The range of incidental lesions included pulmonary nodules, thyroid nodules, and other mediastinal and cervical lesions, predominantly lym- phadenopathy ( Table 5 ). Over the mean 2.95 years of follow-up (SD, 1.52), none of these patients developed a symptomatic or clinically significant pathology. Of the 3 patients who underwent surgery, 1 underwent hemithyroi- dectomy for a follicular adenoma that had no extracapsular extension and was not compressing on the tracheoesopha- geal groove. A second patient underwent total thyroidect- omy for a dominant intrathyroid nodule that was positive for papillary carcinoma on fine-needle aspiration, and the third patient underwent resection of a benign, submucosal false fold lipoma. The number needed to ‘‘harm’’ was 4. A sensitivity analysis of diagnostic yield revealed a yield of 2.2% for the first 5 years of the study, compared with a yield of 5.1% for the second 5 years of the study. An unpaired 2-sample t test of the difference between these 2 means (2.9%) resulted in a P value of .34.

Hoarseness Vocal fatigue

144 (83) 113 (65) 67 (39) 63 (36) 45 (26) 44 (25) 37 (21) 20 (11)

Increased phonatory effort Decreased vocal projection

Loss of range

Cough

Dysphagia

Pain: odynophagia / odynophonia / laryngeal strain

Breathlessness during voicing

13 (7) 11 (6)

Laryngospasm

On video endoscopy, common findings were subtle vocal fold range-of-motion asymmetries, asymmetrically increased glottic show, and asymmetric velocity of motion. These were seen in 79%, 74%, and 67% of patients, respectively. Asymmetries at rest were less prevalent as were signs of bowing and incomplete closure ( Table 3 ). Of the 174 patients, 5 had CT that revealed an etiologic lesion for their vocal fold paresis, a diagnostic yield of 2.9% (95% confidence interval, 0.94 to 6.6; Table 4 ). Of these 5 CT-positive cases, 1 was positive for malignancy. The patient had an exophytic thyroid nodule with possible compression of the recurrent laryngeal nerve in the ipsilat- eral tracheoesophageal groove. This nodule was positive for papillary thyroid carcinoma on fine-needle aspiration. The patient underwent total thyroidectomy and adjuvant radioac- tive iodine. His paresis did not improve on serial follow-up. Four CT-positive cases were benign: 1 was due to previ- ous thoracic aortic aneurysm repair with dense scarring on CT in the aortopulmonary window. Two cases were due to tracheoesophageal groove masses. One mass was an exo- phytic thyroid nodule and associated tracheoesophageal groove lymph node. The patient underwent a right hemithyr- oidectomy and prelaryngeal lymph node dissection. The final histopathology was a benign follicular adenoma. The other tracheoesophageal groove case was due to a large

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