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Original Research—Laryngology and Neurolaryngology
Etiology and Time to Presentation of
Unilateral Vocal Fold Paralysis
Otolaryngology–
Head and Neck Surgery
2014, Vol. 151(2) 286–293
American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2014
Reprints and permission:
sagepub.com/journalsPermissions.navDOI: 10.1177/0194599814531733
http://otojournal.orgEmily A. Spataro, MD
1
, David J. Grindler, MD
1
, and
Randal C. Paniello, MD
1
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.
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.eduReprinted by permission of Otolaryngol Head Neck Surg. 2014; 151(2):286-293.
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