HSC Section 6 Nov2016 Green Book

Otolaryngology–Head and Neck Surgery 151(2)

is potential for earlier presentation in the remaining 25% of patients. In patients who initially presented to an outside otolaryngologist, there was a significant referral delay of 7.4 months in median presentation time to the WUSM. This also highlights an opportunity for education of the referring physicians of the value of early intervention. For example, a recent study by Young et al 14 found that patients with UVFP had better vocal function after undergoing temporary vocal fold injection (VFI) even after direct benefit of VFI had dissipated, regardless of whether vocal fold mobility had recovered. Yung et al, 26 Arviso et al, 27 and Friedman et al 28 all reported lower rates of thyroplasty in patients who underwent temporary VFI. Bhattacharyya et al 29 found that early medialization within 1 to 4 days after onset of UVFP after thoracic surgery decreased the rate of pneumo- nia and led to a shorter length of stay compared with late medialization. Early intervention for UVFP clearly improves patient outcomes. Early intervention could also involve treatment to prevent synkinesis. In animal studies, it has been found that following UVFP, some degree of reinnervation is evident within 3 months of injury. 22 One strategy that has been proposed is to perform a chemical blockade of reinnervation of the posterior cricoarytenoid muscle using a neurotoxic drug such as vin- cristine. 30,31 In an animal model, this was found to improve adductor recovery if given at 3 months postinjury but not at 5 months, 23 indicating there is a window of opportunity for treatment, after which it becomes too late for effective early intervention strategies. The present study shows that 71% of patients would be eligible for such intervention with current referral patterns. A clinical trial is the next step to determine whether this approach can help these patients. A limitation of this study is that the surgical care at a ter- tiary care referral center skews data due to the greater number of difficult cases with a greater likelihood of nerve injury during surgery. In addition to missing data from those with incomplete charts, there are also an unknown number of patients who may have had a vocal fold paralysis but, due to quick recovery of voice, never sought treatment at a tertiary care facility. Future directions of this study include analysis of the ini- tial treatment and outcomes for each etiology of UVFP. Outcomes include voice improvement and return of vocal fold motion by fiberoptic examination. This analysis would allow further correlation with specific UVFP etiologies with the natural history of the disease, effectiveness of treatment, and type of treatment received. Outcomes specific to the length of time from symptom onset to treatment can also be assessed. This assessment would determine if delay in treat- ment adversely affects outcomes. Conclusion This retrospective medical record review of 938 patients with UVFP over the past 10 years is the largest series to date. It expands on the previous reports of UVFP etiology, with surgery and specifically thyroid surgery being the most common causes of UVFP. This study also reflects the

growing contribution of nonthyroid surgeries accounting for a significant amount of injury to the recurrent laryngeal nerve, especially on the left side. Presently, 71% of patients with UVFP are seen within 3 months of RLN injury and would be eligible for early intervention procedures. Patients referred from outside otolaryngologists present, on average, after a significant delay. Emily A. Spataro , data analysis, manuscript preparation; David J. Grindler , data collection and analysis, manuscript preparation; Randal C. Paniello , original idea, final manuscript approval and editing. Disclosures Competing interests: None. Sponsorships: None. Funding source: NIH (R01 DC010884)—salary support for senior author (R.C.P.). 1. Titche L. Causes of recurrent laryngeal nerve paralysis. Arch Otolaryngol . 1976;102:249-261. 2. Benninger MS, Gillen JB, Altman JS. Changing etiology of vocal fold immobility. Laryngoscope . 1998;108:1346-1350. 3. Ramadan HH, Wax MK, Avery S. Outcome and changing cause of unilateral vocal cord paralysis. Otolaryngol Head Neck Surg . 1998;118:199-202. 4. Kearsley JH. Vocal Cod paralysis—an aetiologic review of 100 cases over 20 years. Aust NZ J Med . 1981;11:663-666. 5. Barondess JA, Pompel P, Schley W. A study of vocal cord paralysis. Trans Am Clin Climatol Assoc . 1985;97:141-148. 6. Maisel RH, Ogura JH. Evaluation and treatment of vocal cord paralysis. Laryngoscope . 1974;84:302-316. 7. Hirose H, Sawashima M, Yoshioka H. Clinical observations on 750 cases of laryngeal palsy. Tokyo J Med Sci . 1981;88:33- 37. 8. Hirose H. Clinical observations on 600 cases of recurrent lar- yngeal nerve paralysis. Auris Nasus Larynx . 1978;5:39-48. 9. Leon X, Venegas MP, Orus C, Quer M, Maranillo E, Sanudo JR. Glottic immobility: retrospective study of 229 cases. Acta Otolaryngol Esp . 2001;52:486-492. 10. Yamada M, Hirano M, Ohkubo H. Recurrent laryngeal nerve paralysis: a 10-year review of 564 patients. Auris Nasus Larynx . 1983;10(suppl):S1-S15. 11. Parnell FW, Bandenbug JH. Vocal cord paralysis: a review of 100 cases. Laryngoscope . 1970;80:1036-1045. 12. Chen HC, Jen YM, Wang CH, et al. Etiology of vocal cord paralysis. ORL J Otorhinolaryngol Relat Spec . 2007;69:167-171. 13. Sielska-Badurek E, Domeracka-Kolodziej A, Zawadzka R, Debowska-Jarzebska E. Vocal fold paralysis in the medical university of Warsaw’s ambulatory of phoniatry in years 2000- 2011. Otolaryngol Pol . 2012;66:313-317. 14. Young VN, Smith LJ, Rosen C. Voice outcome following acute unilateral vocal cord paralysis. Ann Otol Rhinol Laryngol . 2013;2122:197-204. Author Contributions References

23