248 / 412
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.
Author Contributions
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.).
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