33 / 412
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
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.
Table 3.
Videostroboscopic Findings of Paresis Subjects Included
in this Study.
Examination Feature
n (%)
Asymmetry of velocity of movement
138 (79)
Increased glottic show
129 (74)
Asymmetry of range of movement
117 (67)
Phase asymmetry
91 (66)
Supraglottic hyperfunction
72 (41)
Incomplete closure
65 (37)
Bowing/atrophy of vocal fold
45 (26)
Deviation
26 (15)
Increased vibratory amplitude
17 (12)
Table 2.
Symptoms of Paresis Subjects Included in this Study.
Symptom
n (%)
Hoarseness
144 (83)
Vocal fatigue
113 (65)
Increased phonatory effort
67 (39)
Decreased vocal projection
63 (36)
Loss of range
45 (26)
Cough
44 (25)
Dysphagia
37 (21)
Pain: odynophagia / odynophonia / laryngeal strain
20 (11)
Breathlessness during voicing
13 (7)
Laryngospasm
11 (6)
Table 1.
Demographic Data of IUVFP by Workup Groups: CT and
Non-CT.
a
CT
Non-CT
Total unilateral paresis
174
63
Age, y
b
54.5 (21-82)
53.9 (18-75)
Women
98 (56)
33 (52)
Left laterality
88 (51)
33 (52)
Abbreviations: CT, computed tomography; IUVFP, idiopathic unilateral vocal
fold paresis.
a
Results presented as n (%), except where noted otherwise.
b
Mean (range).
Otolaryngology–Head and Neck Surgery 153(3)
13