International Journal of Head and Neck Surgery

Register      Login

VOLUME 12 , ISSUE 4 ( October-December, 2021 ) > List of Articles

Invited Review Articles

Vocal Cord Paralysis: Pathophysiology, Etiologies, and Evaluation

Mostafa Alwan, Paul M Paddle

Citation Information : Alwan M, Paddle PM. Vocal Cord Paralysis: Pathophysiology, Etiologies, and Evaluation. Int J Head Neck Surg 2021; 12 (4):153-160.

DOI: 10.5005/jp-journals-10001-1515

License: CC BY-NC 4.0

Published Online: 21-05-2022

Copyright Statement:  Copyright © 2021; The Author(s).


Abstract

Vocal fold paralysis often leads to significant morbidity including dysphonia, dysphagia and aspiration. An appropriate understanding of the pathophysiology, etiologies, and a systematic method of evaluation are essential for discussing prognosis and offering patients appropriate treatments. This article presents a discussion of the most recent literature surrounding vocal cord paralysis, specifically the pathophysiology and different etiologies, and proposes an evaluation strategy involving history, examination and targeted investigations.


HTML PDF Share
  1. Rubin AD, Sataloff RT. Vocal fold paresis and paralysis. Otolaryngol Clin North Am 2007;40(5):1109–1131, viii-ix. DOI: 10.1016/j.otc.2007.05.012
  2. Fontenot TE, Randolph GW, Friedlander PL, et al. Gender, race, and electrophysiologic characteristics of the branched recurrent laryngeal nerve. Laryngoscope 2014;124(10):2433–2437. DOI: 10.1002/lary.24631
  3. Mattsson P, Hydman J, Svensson M. Recovery of laryngeal function after intraoperative injury to the recurrent laryngeal nerve. Gland Surg 2015;4(1):27–35. DOI: 10.3978/j.issn.2227-684X.2015.01.10
  4. Bakalinis E, Makris I, Demesticha T, et al. Non-recurrent laryngeal nerve and concurrent vascular variants: a review. Acta Med Acad 2018;47(2):186–192. DOI: 10.5644/ama2006-124.230
  5. Crumley RL. Unilateral recurrent laryngeal nerve paralysis. J Voice 1994;8(1):79–83. DOI: 10.1016/s0892-1997(05)80323-6
  6. Pascual-Font A, Cubillos L, Vazquez T, et al. Are the interarytenoid muscles supplied by branches of both the recurrent and superior laryngeal nerves? Laryngoscope 2016;126(5):1117–1122. DOI: 10.1002/lary.25375
  7. Meyer TK. The larynx for neurologists. Neurologist 2009;15(6):313–318. DOI: 10.1097/nrl.0b013e3181b1cde5
  8. Choi HS, Ye M, Berke GS. Function of the interarytenoid(IA) muscle in phonation: in vivo laryngeal model. Yonsei Med J 1995;36(1):58–67. DOI: 10.3349/ymj.1995.36.1.58
  9. Hydman J, Bjorck G, Persson JK, et al. Diagnosis and prognosis of iatrogenic injury of the recurrent laryngeal nerve. Ann Otol Rhinol Laryngol 2009;118(7):506–511. DOI: 10.1177/000348940911800709
  10. Scheib J, Hoke A. Advances in peripheral nerve regeneration. Nat Rev Neurol 2013;9(12):668–676. DOI: 10.1038/nrneurol.2013.227
  11. Fawcett JW, Keynes RJ. Peripheral nerve regeneration. Annu Rev Neurosci 1990;13:43–60. DOI: 10.1146/annurev.ne.13.030190.000355
  12. Fournier AE, Strittmatter SM. Regenerating nerves follow the road more traveled. Nat Neurosci 2002;5(9):821–822. DOI: 10.1038/nn0902-821
  13. Shindo ML, Herzon GD, Hanson DG, et al. Effects of denervation on laryngeal muscles: a canine model. Laryngoscope 1992;102(6):663–669. DOI: 10.1288/00005537-199206000-00012
  14. Ivey CM. Vocal fold paresis. Otolaryngol Clin North Am 2019;52(4):637–648. DOI: 10.1016/j.otc.2019.03.008
  15. Myssiorek D. Recurrent laryngeal nerve paralysis: anatomy and etiology. Otolaryngol Clin North Am 2004;37(1):25–44, v. DOI: 10.1016/s0030-6665(03)00172-5
  16. Smith TL, Smith JM. Electrosurgery in otolaryngology-head and neck surgery: principles, advances, and complications. Laryngoscope 2001;111(5):769–780. DOI: 10.1097/00005537-200105000-00004
  17. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope 2007;117(10):1864–1870. DOI: 10.1097/MLG.0b013e3180de4d49
  18. Abadin SS, Kaplan EL, Angelos P. Malpractice litigation after thyroid surgery: the role of recurrent laryngeal nerve injuries, 1989–2009. Surgery 2010;148(4):718–722; discussion 22–3. DOI: 10.1016/j.surg.2010.07.019
  19. Collazo-Clavell ML, Gharib H, Maragos NE. Relationship between vocal cord paralysis and benign thyroid disease. Head Neck 1995;17(1):24–30. DOI: 10.1002/hed.2880170106
  20. Rowe-Jones JM, Rosswick RP, Leighton SE. Benign thyroid disease and vocal cord palsy. Ann R Coll Surg Engl 1993;75(4):241–244. PMID: 8379624.
  21. Bergamaschi R, Becouarn G, Ronceray J, et al. Morbidity of thyroid surgery. Am J Surg 1998;176(1):71–75. DOI: 10.1016/s0002-9610(98)00099-3
  22. Hermann M, Alk G, Roka R, et al. Laryngeal recurrent nerve injury in surgery for benign thyroid diseases: effect of nerve dissection and impact of individual surgeon in more than 27,000 nerves at risk. Ann Surg 2002;235(2):261–268. DOI: 10.1097/00000658-200202000-00015
  23. Cernea CR, Hojaij FC, De Carlucci D, Jr., et al. Recurrent laryngeal nerve: a plexus rather than a nerve? Arch Otolaryngol Head Neck Surg 2009;135(11):1098–1102. DOI: 10.1001/archoto.2009.151
  24. Affleck BD, Swartz K, Brennan J. Surgical considerations and controversies in thyroid and parathyroid surgery. Otolaryngol Clin North Am 2003;36(1):159–187. DOI: 10.1016/s0030-6665(02)00135-4
  25. More Y, Shnayder Y, Girod DA, et al. Factors influencing morbidity after surgical management of malignant thyroid disease. Ann Otol Rhinol Laryngol 2013;122(6):398–403. DOI: 10.1177/000348941312200609
  26. Tucker HM. Vocal cord paralysis–1979: etiology and management. Laryngoscope 1980;90(4):585–590. DOI: 10.1288/00005537-198004000-00004
  27. Shindo M, Chheda NN. Incidence of vocal cord paralysis with and without recurrent laryngeal nerve monitoring during thyroidectomy. Arch Otolaryngol Head Neck Surg 2007;133(5):481–485. DOI: 10.1001/archotol.133.5.481
  28. Echeverri A, Flexon PB. Electrophysiologic nerve stimulation for identifying the recurrent laryngeal nerve in thyroid surgery: review of 70 consecutive thyroid surgeries. Am Surg 1998;64(4):328–333. PMID: 9544143.
  29. Maroulis J, Karkanevatos A, Papakostas K, et al. Cranial nerve dysfunction following carotid endarterectomy. Int Angiol 2000;19(3):237–241. PMID: 11201592.
  30. Hertzer NR, Feldman BJ, Beven EG, et al. A prospective study of the incidence of injury to the cranial nerves during carotid endarterectomy. Surg Gynecol Obstet 1980;151(6):781–784. PMID: 7444729
  31. Dehn TC, Taylor GW. Cranial and cervical nerve damage associated with carotid endarterectomy. Br J Surg 1983;70(6):365–368. DOI: 10.1002/bjs.1800700619
  32. Morpeth JF, Williams MF. Vocal fold paralysis after anterior cervical diskectomy and fusion. Laryngoscope 2000;110(1):43–46. DOI: 10.1097/00005537-200001000-00009
  33. Apfelbaum RI, Kriskovich MD, Haller JR. On the incidence, cause, and prevention of recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine (Phila Pa 1976) 2000;25(22):2906–2912. DOI: 10.1097/00007632-200011150-00012
  34. Ebraheim NA, Lu J, Skie M, et al. Vulnerability of the recurrent laryngeal nerve in the anterior approach to the lower cervical spine. Spine (Phila Pa 1976) 1997;22(22):2664–2667. DOI: 10.1097/00007632-199711150-00015
  35. Menovsky T, van Overbeeke JJ. On the mechanism of transient postoperative deficit of cranial nerves. Surg Neurol 1999;51(2):223–226. DOI: 10.1016/s0090-3019(97)00510-7
  36. Netterville JL, Jackson CG, Miller FR, et al. Vagal paraganglioma: a review of 46 patients treated during a 20-year period. Arch Otolaryngol Head Neck Surg 1998;124(10):1133–1140. DOI: 10.1001/archotol.124.10.1133
  37. Sengupta A, Dubey SP, Chaudhuri D, et al. Ortner's syndrome revisited. J Laryngol Otol 1998;112(4):377–379. DOI: 10.1017/s0022215100140514
  38. Filaire M, Mom T, Laurent S, et al. Vocal cord dysfunction after left lung resection for cancer. Eur J Cardiothorac Surg 2001;20(4):705–711. DOI: 10.1016/s1010-7940(01)00819-3
  39. Chai YJ, Lee JM, Seong YW, et al. Application of continuous intraoperative neuromonitoring during VATS lobectomy for left lung cancer to prevent recurrent laryngeal nerve injury. Sci Rep 2020;10(1):4636. DOI: 10.1038/s41598-020-61500-6
  40. Sniezek JC, Netterville JL, Otolaryngol Clin North Am Sabri AN. Vagal paragangliomas. 2001;34(5):925–939, vi. DOI: 10.1016/s0030-6665(05)70355-8
  41. Ramadan HH, Wax MK, Avery S. Outcome and changing cause of unilateral vocal cord paralysis. Otolaryngol Head Neck Surg 1998;118(2):199–202. DOI: 10.1016/S0194-5998(98)80014-4
  42. Brandwein M, Abramson AL, Shikowitz MJ. Bilateral vocal cord paralysis following endotracheal intubation. Arch Otolaryngol Head Neck Surg 1986;112(8):877–882. DOI: 10.1001/archotol.1986.03780080077018
  43. Marie JP, Keghian J, Mendel I, et al. Post-intubation vocal cord paralysis: the viral hypothesis. A case report. Eur Arch Otorhinolaryngol 2001;258(6):285–286. DOI: 10.1007/s004050100357
  44. Friedrich T, Hansch U, Eichfeld U, et al. [Recurrent laryngeal nerve paralysis as intubation injury?]. Chirurg 2000;71(5):539–544. DOI: 10.1007/s001040051099
  45. Bachor E, Bonkowsky V, Hacki T. Herpes simplex virus type I reactivation as a cause of a unilateral temporary paralysis of the vagus nerve. Eur Arch Otorhinolaryngol 253(4-5):297–300. DOI: 10.1007/BF00171147
  46. 3rd Flowers RH, Kernodle DS. Vagal mononeuritis caused by herpes simplex virus: association with unilateral vocal cord paralysis. Am J Med 1990;88(6):686–688. DOI: 10.1016/0002-9343(90)90542-l
  47. Pou A, Carrau RL. Bilateral abductor vocal cord paralysis in association with herpes simplex infection: a case report. Am J Otolaryngol 1995;16(3):216–219. DOI: 10.1016/0196-0709(95)90108-6
  48. Johns MM, Hogikyan ND. Simultaneous vocal fold and tongue paresis secondary to Epstein-Barr virus infection. Arch Otolaryngol Head Neck Surg 2000;126(12):1491–1494. DOI: 10.1001/archotol.126.12.1491
  49. Parano E, Pavone L, Musumeci S, et al. Acute palsy of the recurrent laryngeal nerve complicating Epstein-Barr virus infection. Neuropediatrics 1996;27(3):164–166. DOI: 10.1055/s-2007-973769
  50. Bryson A. Neurological complications of influenza A2-Hong Kong-68 virus. Med J Aust 1970;2(14):654. DOI: 10.5694/j.1326-5377.1970.tb50253.x
  51. Wirth G, Leypoldt R. Increased occurrence of vocal cord paralysis during influenza epidemic in the winter 1969–70. Z Laryngol Rhinol Otol 1970;49(12):777–784. PMID: 5509911.
  52. Bhatt NK, Pipkorn P, Paniello RC. Association between upper respiratory infection and idiopathic unilateral vocal fold paralysis. Ann Otol Rhinol Laryngol 2018;127(10):667–671. DOI: 10.1177/0003489418787542
  53. Chitose SI, Umeno H, Hamakawa S, et al. Unilateral associated laryngeal paralysis due to varicella-zoster virus: virus antibody testing and videofluoroscopic findings. J Laryngol Otol 2008;122(2):170–176. DOI: 10.1017/S0022215107000898
  54. Nishizaki K, Onoda K, Akagi H, et al. Laryngeal zoster with unilateral laryngeal paralysis. ORL J Otorhinolaryngol Relat Spec 1997;59(4):235–237. DOI: 10.1159/000276944
  55. Randel RC, Kearns DB, Nespeca MP, et al. Vocal cord paralysis as a presentation of intrauterine infection with varicella-zoster virus. Pediatrics 1996;97(1):127–128. DOI: 10.1542/peds.97.1.127
  56. Ueha R, Nito T, Goto T, et al. Bilateral vocal cord immobility resulting from cytomegalovirus pharyngitis: a case report. J Infect Chemother 2018;24(2):142–146. DOI: 10.1016/j.jiac.2017.09.007
  57. de La Blanchardiere A, Dore M, Salmon D, et al. [Left vocal cord paralysis in cytomegalovirus multifocal neuropathy in a patient with HIV infection]. Presse Med 1996;25(3):106–107. PMID: 8746083.
  58. Rontal E, Rontal M, Wald J, et al. Botulinum toxin injection in the treatment of vocal fold paralysis associated with multiple sclerosis: a case report. J Voice 1999;13(2):274–279. DOI: 10.1016/s0892-1997(99)80032-0
  59. Tyler HR. Neurology of the larynx. Otolaryngol Clin North Am 1984;17(1):75–79. DOI: 10.1016/s0030-6665(20)31997-6
  60. Isozaki E, Osanai R, Horiguchi S, et al. Laryngeal electromyography with separated surface electrodes in patients with multiple system atrophy presenting with vocal cord paralysis. J Neurol 1994;241(9):551–556. DOI: 10.1007/BF00873518
  61. Cridge PB, Allegra J, Gerhard H. Myasthenic crisis presenting as isolated vocal cord paralysis. Am J Emerg Med 2000;18(2):232–233. DOI: 10.1016/s0735-6757(00)90031-7
  62. Yoskovitch A, Enepekides DJ, Hier MP, et al. Guillain-Barre syndrome presenting as bilateral vocal cord paralysis. Otolaryngol Head Neck Surg 2000;122(2):269–270. DOI: 10.1016/S0194-5998(00)70253-1
  63. Plasse HM, Lieberman AN. Bilateral vocal cord paralysis in Parkinson's disease. Arch Otolaryngol 1981;107(4):252–253. DOI: 10.1001/archotol.1981.00790400054013
  64. Venketasubramanian N, Seshadri R, Chee N. Vocal cord paresis in acute ischemic stroke. Cerebrovasc Dis 1999;9(3):157–162. DOI: 10.1159/000015947
  65. Vachha B, Cunnane MB, Mallur P, et al. Losing your voice: etiologies and imaging features of vocal fold paralysis. J Clin Imaging Sci 2013;3:15. DOI: 10.4103/2156-7514.109751
  66. Leszczynski P, Pawlak-Bus K. Vocal cords palsy in systemic lupus erythematosus patient: diagnostic and therapeutic difficulties. Rheumatol Int 2013;33(6):1577–1580. DOI: 10.1007/s00296-012-2615-x
  67. Hughes M, Hill J. Left vocal cord paralysis in systemic lupus erythematosus. Mod Rheumatol 2009;19(4):441–442. DOI: 10.1007/s10165-009-0178-9
  68. Benninger MS, Gillen JB, Altman JS. Changing etiology of vocal fold immobility. Laryngoscope 1998;108(9):1346–1350. DOI: 10.1097/00005537-199809000-00016
  69. Richardson BE, Bastian RW. Clinical evaluation of vocal fold paralysis. Otolaryngol Clin North Am 2004;37(1):45–58. DOI: 10.1016/s0030-6665(03)00179-8
  70. Maryn Y, De Bodt MS, Van Cauwenberge PV. Ventricular dysphonia: clinical aspects and therapeutic options. Laryngoscope 2003;113(5):859–866. DOI: 10.1097/00005537-200305000-00016
  71. Lynch J, Parameswaran R. Management of unilateral recurrent laryngeal nerve injury after thyroid surgery: a review. Head Neck 2017;39(7):1470–1478. DOI: 10.1002/hed.24772
  72. Reghunathan S, Bryson PC. Components of voice evaluation. Otolaryngol Clin North Am 2019;52(4):589–595. DOI: 10.1016/j.otc.2019.03.002
  73. Watanabe K, Sato T, Honkura Y, et al. Characteristics of the voice handicap index for patients with unilateral vocal fold paralysis who underwent arytenoid adduction. J Voice 2020;34(4):649.e1–649.e6. DOI: 10.1016/j.jvoice.2018.12.012
  74. Almeida AA, Fernandes LR, Azevedo EH, et al. Characteristics of voice and personality of patients with vocal fold immobility. Codas 2015;27(2):178–185. DOI: 10.1590/2317-1782/20152014144
  75. Rubin AD, Sataloff RT. Vocal fold paresis and paralysis: what the thyroid surgeon should know. Surg Oncol Clin N Am 2008;17(1):175–196. DOI: 10.1016/j.soc.2007.10.007
  76. Tabaee A, Murry T, Zschommler A, et al. Flexible endoscopic evaluation of swallowing with sensory testing in patients with unilateral vocal fold immobility: incidence and pathophysiology of aspiration. Laryngoscope 2005;115(4):565–569. DOI: 10.1097/01.mlg.0000161358.20450.12
  77. Benninger MS, Crumley RL, Ford CN, et al. Evaluation and treatment of the unilateral paralyzed vocal fold. Otolaryngol Head Neck Surg 1994;111(4):497–508. DOI: 10.1177/019459989411100419
  78. Sulica L. Laryngoscopy, stroboscopy and other tools for the evaluation of voice disorders. Otolaryngol Clin North Am 2013;46(1):21–30. DOI: 10.1016/j.otc.2012.09.001
  79. Woo P, Casper J, Colton R, et al. Diagnosis and treatment of persistent dysphonia after laryngeal surgery: a retrospective analysis of 62 patients. Laryngoscope 1994;104(9):1084–1091. DOI: 10.1288/00005537-199409000-00007
  80. Sataloff RT, Spiegel JR, Hawkshaw MJ. Strobovideolaryngoscopy: results and clinical value. Ann Otol Rhinol Laryngol 1991;100(9 Pt 1):725–727. DOI: 10.1177/000348949110000907
  81. Casiano RR, Zaveri V, Lundy DS. Efficacy of videostroboscopy in the diagnosis of voice disorders. Otolaryngol Head Neck Surg 1992;107(1):95–100. DOI: 10.1177/019459989210700115
  82. Knudsen R, Gaunsbaek MQ, Schultz JH, et al. Vocal cord paralysis as primary and secondary results of malignancy. A prospective descriptive study. Laryngoscope Investig Otolaryngol 2019;4(2):241–245. DOI: 10.1002/lio2.251
  83. Chang WH, Fang TJ, Li HY, et al. Quantitative electromyographic characteristics of idiopathic unilateral vocal fold paralysis. Laryngoscope 2016;126(11):E362–E368. DOI: 10.1002/lary.25944
  84. Smith LJ, Rosen CA, Niyonkuru C, et al. Quantitative electromyography improves prediction in vocal fold paralysis. Laryngoscope 2012;122(4):854–859. DOI: 10.1002/lary.21884
  85. Heman-Ackah YD, Mandel S, Manon-Espaillat R, et al. Laryngeal electromyography. Otolaryngol Clin North Am 2007;40(5):1003–1023, vi-vii. DOI: 10.1016/j.otc.2007.05.007
  86. Munin MC, Rosen CA, Zullo T. Utility of laryngeal electromyography in predicting recovery after vocal fold paralysis. Arch Phys Med Rehabil 2003;84(8):1150–1153. DOI: 10.1016/s0003-9993(03)00146-1
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.