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Original Research—Laryngology and Neurolaryngology
Diagnostic Yield of Computed
Tomography in the Evaluation of
Idiopathic Vocal Fold Paresis
Otolaryngology–
Head and Neck Surgery
2015, Vol. 153(3) 414–419
American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2015
Reprints and permission:
sagepub.com/journalsPermissions.navDOI: 10.1177/0194599815593268
http://otojournal.orgPaul M. Paddle, MD, MPH
1
, Masaany B. Mansor, MD
1
,
Phillip C. Song, MD
1
, and Ramon A. Franco Jr, MD
1
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective.
To determine the diagnostic yield of computed
tomography (CT) in establishing an etiology in patients with
idiopathic unilateral vocal fold paresis (IUVFP). To determine
the proportion of CT scans yielding incidental findings
requiring further patient management.
Study Design.
Case series with chart review.
Setting.
Tertiary laryngology practice.
Subjects.
Laryngology clinic patients under the care of the 2
senior authors.
Methods.
All clinic patients were identified who had a diag-
nosis of IUVFP and underwent CT of the skull base to the
upper mediastinum from 2004 to 2014. Demographic, his-
torical, examination, and investigation data were extracted.
CT reports and endoscopic recordings were reviewed.
Patients were excluded if there were insufficient clinical find-
ings recorded or if there was a known neurologic disorder,
complete vocal fold immobility, or bilateral involvement.
Results.
A total of 174 patients with IUVFP who had also
undergone contrast-enhanced CTwere identified. Of the 174
patients, 5 had a cause for their paresis identified on CT. This
equated to a diagnostic yield of 2.9% (95% confidence inter-
val, 0.94% to 6.6%). Of the 174 patients, 48 had other inci-
dental lesions identified that required further follow-up,
investigation, or treatment. This equated to an incidental
yield of 27.6% (95% confidence interval, 21.1% to 34.9%).
Conclusion.
This is the second and largest study to evaluate
the diagnostic yield of CT in the evaluation of IUVFP. It
demonstrates a low diagnostic yield and a high incidental
yield. These findings suggest that the routine use of CT in the
evaluation of idiopathic vocal fold paresis should be given
careful consideration and that a tailored approach to investi-
gation with good otolaryngologic follow-up is warranted.
Keywords
idiopathic unilateral vocal fold paresis, computed tomogra-
phy, diagnostic yield, incidental yield
Received October 26, 2014; revised May 6, 2015; accepted June 5,
2015.
V
ocal fold paresis implies vocal fold hypomobility
due to neurologic injury, with a peripheral etiology
in 90% of cases. It may result from weakness of the
vagus nerve or its superior or recurrent laryngeal branches.
This may occur anywhere in its course—from the lower
motor neurons in the nucleus ambiguus of the medulla
through the jugular foramen, neck, and mediastinum. Vocal
fold paresis is unilateral in 90% of cases.
1
Paresis is the most common cause of vocal fold hypomo-
bility, being present in 90% of cases.
1
Other causes of vocal
fold hypomobility include myopathies (4%) and cricoaryte-
noid joint dysfunction (6%). Paresis is an increasingly
recognized phenomenon in patients with laryngologic com-
plaints. Previous studies reported mild vocal fold hypomobi-
lity in 46% of patients with vocal complaints, 71% of
singing teachers with complaints of technical difficulties,
and 23% of singing teachers with no vocal complaints.
1,2
Diagnosis of vocal fold paresis requires a high index of sus-
picion. The symptoms of vocal fold paresis are more varied
and subtle than paralysis. Classic symptoms of glottic
insufficiency—such as breathy dysphonia, diplophonia, aspira-
tion, and dysphagia—may be absent or muted. Instead, the
patient may complain of a loss of quality volume and range,
vocal instability, and increased phonatory effort.
3
Atypical
symptoms, such as globus, chronic cough, and laryngospasm,
are also described.
Unlike the findings of an established vocal fold paralysis,
such as vocal fold atrophy, bowing, and arytenoid prolapse,
the examination findings of unilateral vocal fold paresis are
subtle and difficult to discern from nonpathologic asymme-
tries. Findings may include asymmetric vocal fold range
and velocity of movement, decreased ipsilateral false vocal
1
Harvard Medical School, Division of Laryngology, Massachusetts Eye and
Ear Infirmary, Boston, Massachusetts, USA
Corresponding Author:
Paul M. Paddle, MD, Harvard Medical School, Division of Laryngology,
Massachusetts Eye and Ear Infirmary, Boston, MA 02114, USA.
Email:
paulpaddle@me.comReprinted by permission of Otolaryngol Head Neck Surg. 2015; 153(3):414-419.
11