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Reprinted by permission of Otolaryngol Head Neck Surg. 2014; 151(2):286-293.

Original Research—Laryngology and Neurolaryngology

Otolaryngology– Head and Neck Surgery 2014, Vol. 151(2) 286–293 American Academy of Otolaryngology—Head and Neck

Etiology and Time to Presentation of Unilateral Vocal Fold Paralysis

Surgery Foundation 2014 Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814531733 http://otojournal.org

Emily A. Spataro, MD 1 , David J. Grindler, MD 1 , and Randal C. Paniello, MD 1

T he etiology of unilateral vocal fold paralysis (UVFP) is of great interest to the otolaryngologist and has been reported in many studies over the past 40 years. 1-19 Etiologies include thyroid surgery, nonthyroid sur- gery, trauma, neurologic disease, malignancy, intubation, infection, inflammatory diseases, and idiopathic causes. Among past studies, there is great discrepancy between the most common causes of vocal fold paralysis. The most common have included lung malignancies, 1-5 idiopathic causes, 2,6-10 thyroid surgery, 11-16 and nonthyroid sur- geries. 15-18 In 2 recent large retrospective chart review stud- ies, thyroid surgery was the single most common cause of UVFP, but nonthyroid surgeries as a group more commonly cause UVFP. 15,16 The etiology of UVFP is important because it affects the natural course, treatment, and outcome of the condition. Both the mechanism and degree of injury are important, ranging from neuropraxia, where complete recovery is expected, to complete transection, which may require surgi- cal intervention. 20 Outcomes are affected by contralateral vocal fold compensation, as well as the degree of reinnerva- tion and synkinesis established. 20 In a recent review of idio- pathic UVFP, most improvement of vocal fold function and voice occurred within the first year of injury. 21 Treatment of UVFP includes voice therapy, permanent and nonpermanent medialization procedures, and reinnerva- tion. If the etiology suggests the nerve was not transected, then some degree of recovery of laryngeal nerve function is expected, and nonpermanent treatments are generally rec- ommended until 6 to 12 months after onset of paralysis, whereas if complete transection has occurred, permanent medialization or reinnervation procedures may be underta- ken sooner. 20 In addition, voice and airway are affected by the degree of synkinesis present. Synkinesis is caused by 1 Department of Otolaryngology–Head and Neck Surgery, Washington, University School of Medicine, St Louis, Missouri, USA This article was presented at the 2013 AAO-HNSF Annual Meeting & OTO EXPO; September 29–October 3, 2013; Vancouver, British Columbia, Canada. Corresponding Author: Randal C. Paniello, MD, Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8115, St Louis, MO 63110, USA. Email: paniellor@ent.wustl.edu

Sponsorships or competing interests that may be relevant to content are dis- closed at the end of this article.

Abstract Objective . To determine the etiology, laterality, and time to presentation of unilateral vocal fold paralysis (UVFP) at a tertiary care institution over 10 years.

Study Design . Case series with chart review.

Setting . Academic medical center.

Subjects and Methods . All patients seen between 2002 and 2012 by the Department of Otolaryngology at the Washington University School of Medicine (WUSM), with a diagnosis of unilateral vocal fold paralysis, were included. Medical records were reviewed for symptom onset date, presentation date(s), and etiology of UVFP. Results . Of the patients, 938 met inclusion criteria and were included. In total, 522 patients (55.6%) had UVFP due to sur- gery; 158 (16.8%) were associated with thyroid/parathyroid surgery, while 364 (38.8%) were due to nonthyroid surgery. Of the patients, 416 (44.4%) had nonsurgical etiologies, 124 (13.2%) had idiopathic UVFP, and 621 (66.2%) had left-sided UVFP. The diagnosis was more common on the left side in cases of intrathoracic surgeries and malignancies, as expected, but also in idiopathic, carotid endarterectomy, intubation, and skull base tumors. In total, 9.8% of patients presented first to an outside otolaryngologist at a median time of 2.1 months after onset, but these patients presented to WUSM at a median time of 9.5 months. Overall, 70.6% of patients presented to a WUSM otolaryngologist within 3 months of onset. Conclusion . Iatrogenic injury remains the most common cause of UVFP. Thyroidectomy remains the leading cause of surgery- related UVFP. Patients are typically seen within 3-4 months of onset; however, a significant delay exists for those referred to WUSM.

Keywords vocal cord, paralysis, etiology

Received October 31, 2013; revised February 3, 2014; accepted March 25, 2014.

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