Originl Pper ORL 2007;69:167 171 DOI: 10.1159/000099226 Received: Mrch 6, 2006 Accepted fter revision: August 25, 2006 Published online: Jnury 30, 2007 Etiology of Vocl Cord Prlysis Hsin-Chien Chen Yee-Min Jen b Chih-Hung Wng Jih-Chin Lee Yoh-Shing Lin Deprtments of Otolryngology, Hed nd Neck Surgery nd b Rdition Oncology, Tri-Service Generl Hospitl, Ntionl Defense Medicl Center, Tipei, Tiwn, ROC Key Words Recurrent lryngel nerve Vocl cord prlysis, etiology Abstrct Objective: Vocl cord prlysis (VCP) is sign of certin underlying disese, dignosis which cn be ttributed to vrious cuses. This study intends to nlyze the contemporry etiology of VCP in tertiry medicl center. Mterils nd Methods: A retrospective review of medicl records from June 2000 to December 2004 of hospitlized ptients with VCP ws done to determine the etiology. Results: Two hundred nd ninety-one ptients with determined etiology were identified, consisting of 176 mles nd 115 femles. Unilterl VCP ws present in 259 ptients, while 32 presented with bilterl VCP. The cuses were surgicl in 40.2, neoplstic in 29.9, idiopthic in 10.7, trumtic in 8, centrl in 3.8, rdition-induced in 3.4, inflmmtory in 2, crdiovsculr in 1.7 nd other cuses in 0.3 of the cses. Thyroidectomy represented the most common surgery for VCP nd ws the cuse in 57 ptients. Lung cncer ws responsible for 34 cses nd ws the most common neoplstic etiology. In mles, neoplsm ws the most common cuse occurring in 63 of 176 mles, wheres surgery ws most frequent in 59 of 115 femles. Conclusion: Surgicl trum, minly thyroidectomy, is the most common cuse of VCP in hospitlized ptients. The possibility of neoplsm must be ruled out before VCP is lbeled idiopthic. A benign thyroid tumor could lso cuse VCP. Besides, rdition-induced crnil nerve prlysis in hed nd neck cncer my ply significnt role. Copyright 2007 S. Krger AG, Bsel Introduction Vocl cord prlysis (VCP), defined s the loss of norml dduction/bduction cused by lesion distnt from the cords, result from neurl injury to the recurrent lryngel nerve. Numerous studies hve documented the cuses of lryngel prlysis, often without greement on wht the most common reson is [1 11]. In generl, the common etiology of VCP includes surgicl procedure, neoplsm nd undefined cuses [1]. However, some uthors hve indicted tht the frequency of the vrious cuses of VCP my be chnging [2 6]. This study ws designed to evlute the contemporry etiology of unilterl nd bilterl VCP other thn primry lryngel nd hypophryngel cncers. Mterils nd Methods The records of ll hospitlized ptients with the dignostic code for VCP were retrospectively reviewed from June 2000 to December 2004 in the Tri-Service Generl Hospitl. Records were nlyzed for the following informtion: sex, ge, side of prlysis Fx +41 61 306 12 34 E-Mil krger@krger.ch www.krger.com 2007 S. Krger AG, Bsel 0301 1569/07/0693 0167$23.50/0 Accessible online t: www.krger.com/orl Yoh-Shing Lin, MD Deprtment of Otolryngology, Hed nd Neck Surgery, Tri-Service Generl Hospitl 325 Cheng-Kung Rod, Sec. 2, Neihu District Tipei 114, Tiwn (ROC) Tel. +886 2 8792 7192, Fx +886 2 8792 7193, E-Mil yskuolin@ndmctsgh.edu.tw
80 70 67 73 60 Ptients (n) 50 40 30 25 48 45 20 10 0 1 1 10 16 12 4 11 20 21 30 31 40 41 50 51 60 61 70 71 80 81 90 Age (yers) Fig. 1. Age distribution. Tble 1. Etiology of unilterl nd bilterl VCP Etiology Sex Unilterl Bilterl M F totl M F totl M F totl Surgery 58 59 117 (40.2) 54 48 102 4 11 15 Neoplsm 63 24 87 (29.9) 60 21 81 3 3 6 Idiopthic 15 16 31 (10.7) 14 14 28 1 2 3 Trum 19 4 23 (8) 17 3 20 2 1 3 CNS 8 3 11 (3.8) 7 2 9 1 1 2 Rdition 7 3 10 (3.4) 6 2 8 1 1 2 Inflmmtion 3 3 6 (2) 3 2 5 0 1 1 CVS 3 2 5 (1.7) 3 2 5 0 0 0 Others 0 1 1 (0.3) 0 1 1 0 0 0 Totl 176 115 291 (100) 164 95 259 12 20 32 CVS = Crdiovsculr system. Figures in prentheses indicte percentges. nd cuse of prlysis. VCP ws confirmed vi mirror or flexible or rigid lryngoscopy. The etiology of vocl immobility ws determined by history nd complete hed nd neck exmintion. Other exmintions, such s chest rdiogrphy, ultrsonic echogrphy of the neck nd CT or MRI were performed when indicted. Ptients with primry mlignncies of the hypophrynx nd lrynx were excluded. The etiologies were ctegorized to llow comprisons to previous mjor studies. Idiopthic prlysis ws ssigned if cuse for VCP could not be determined fter n dequte dignostic evlution. R e s u l t s There were 291 ptients identified with vocl cord prlysis: 259 cses with unilterl VCP nd 32 with bilterl VCP. There were 176 mles nd 115 femles. The men ge t dignosis ws 54 yers with rnge from 10 to 88 yers ( fig. 1 ). The cuses for unilterl nd bilterl VCP, nd the sex distribution, re listed in tble 1. Surgery ws the most common cuse, ccounting for 117 ptients (40.2). The min surgicl procedures included 168 ORL 2007;69:167 171 Chen /Jen /Wng /Lee /Lin
Tble 2. Types of surgery cusing VCP Types of surgery Totl Unilterl Bilterl Thyroid tumor 57 45 12 Benign 47 38 9 Mlignnt 10 7 3 Esophgus 13 11 2 Hert 11 10 1 Neck tumor 10 10 0 Thorx 9 9 0 Medistinum 5 5 0 Cervicl spine 4 4 0 Skull bse 3 3 0 Trcheostomy 2 2 0 Brin 1 1 0 Prthyroid 1 1 0 Cervicl crotid rtery 1 1 0 Totl 117 102 15 Tble 3. Neoplsms cusing VCP Types of neoplsm Totl Unilterl Bilterl Lung cncer 34 34 0 Esophgus cncer 9 9 0 Brest cncer 9 9 0 Thyroid cncer 8 6 2 NPC 5 5 0 Benign thyroid tumor 4 4 0 Colon cncer 3 3 0 Skull bse tumor 2 2 0 Gstric cncer 1 1 0 Medistinl tumor 1 0 1 Brin tumor 1 0 1 Others 10 8 2 Totl 87 81 6 thyroidectomy in 57 ptients, surgery on the esophgus in 13, the hert in 11, the neck in 10 nd the thorx in 9 ( tble 2 ). Neoplsm ws the second most common cuse. In the 87 ptients (29.9) with neoplstic cuse, 34 hd lung cncer, 9 hd esophgus cncer, 9 hd brest cncer, 8 hd thyroid cncer, 5 hd nsophryngel cncer (NPC), 4 hd benign thyroid tumor, 3 hd colon cncer, 2 hd neoplsm of the skull bse nd others ( tble 3 ). Idiopthic prlysis ws the third in the etiology list, nd ws noted in 31 ptients (10.7). Trum ws the cuse of VCP in 23 ptients (8), with intubtion injury being the most common cuse in 11 of these. In 11 ptients (3.8), VCP ws the result of centrl lesion. In ddition, rdition-induced VCP ccounted for 10 ptients (3.4), nd 9 of these were NPC cses. In 6 ptients (2), VCP ws the result of n inflmmtory process nd in 5 ptients (1.7) it ws cused by crdiovsculr disese. Regrding gender, neoplsm ws the most common etiology in mles, ccounting for 63 ptients, followed by surgery in 58 cses. In femles, surgery ws the most common cuse nd ws responsible for 59 ptients, followed by neoplsm in 24 ptients. In ptients with unilterl VCP, left VCP ws found in 179 ptients (69), wheres the right vocl cord ws prlyzed in 80 ptients (31). One hundred nd sixty-four ptients were men nd 95 were women. One hundred nd two cses were secondry to surgery (102/259), 44.1 were due to thyroidectomy (45/102), followed by esophgel surgery nd open hert surgery. Eighty-one cses were due to neoplsm, 41.9 of which were due to lung cncer (34/81), followed by esophgus nd brest cncer. There were 12 men nd 20 women with bilterl VCP. Like the unilterl VCP, the leding cuse for bilterl VCP ws still surgicl procedure, ccounting for 15 of the 32 cses. Thyroidectomy resulted in most surgiclly relted incidents (12/15). Six cses were secondry to neoplsm, followed by idiopthic prlysis nd trum. Discussion The exct incidence of VCP is difficult to determine. In this study of hospitlized ptients, the incidence of VCP incresed with the ge of the ptient. The pek incidence ws between 51 nd 60 yers. This is likely result of the incresed incidence of cncer nd neurologicl dmge in the older popultion [1]. There were more mle ptients thn femles with unilterl VCP, in contrst to bilterl VCP. The incidence of left VCP ws bout twice s frequent s right VCP. It is comprble with the previous medicl literture [2 5, 7]. The longer course of the left recurrent lryngel curve might ccount for the difference. In the literture, surgery, neoplsm nd idiopthic prlysis were the min three cuses with the rnking for unilterl VCP vrying ( tble 4 ) [1 5, 7 11]. Reports on bilterl VCP re limited. Feehery et l. [6] found tht the cuses for bilterl VCP include thyroidectomy, mlignncy, trum s well s neurologicl nd idiopthic prlysis. Etiology of Vocl Cord Prlysis ORL 2007;69:167 171 169
Tble 4. Min cuses of unilterl VCP Authors Yer Surgery Neoplsm Idiopthic Trum Clerf [8] (n = 293) 1953 23 38 12 Prnell nd Brndenburg [9] (n = 86) 1970 23 36 11 2.3 Titche [10] (n = 128) 1976 9.4 39 2.3 10.9 Shei et l. [7] (n = 283) 1 1979 22 39 11 14.3 Tucker [11] (n = 210) 1980 42 22 14 Terris et l. [4] (n = 84) 1992 34.5 40.5 10.7 8.3 Benninger et l. [2] (n = 280) 1998 24 25 20 18 Rmdn et l. [3] (n = 98) 1998 30 32 16 11 Yumoto et l. [5] (n = 422) 2002 33 19 22 Present study 40.2 29.9 10.7 8 n = Numbers of ptients. 1 The first report in Tiwn (in Chinese). In the erlier literture, neoplsm ws the most common etiology both in Tiwn nd the West [7 10]. In our nlysis, it is surgery. Although some uthors hve suggested tht thyroid surgery is decresing s cuse for VCP due to improved techniques, thyroidectomy is still the most common reson cusing VCP in this study nd most others [2 6]. Esophgel surgery is the second common surgicl cuse. VCP in ptients with cervicl spine opertions nd open hert surgery hs incresed due to more frequent opertions [1 3]. It is worth noting tht the VCP fter cervicl spine surgery ws lwys on the right. The right recurrent lryngel nerve pproches the lrynx t wider ngle thn the left reltive to the sgittl plne. The right is thus t greter risk thn the left when the Clowrd retrctor is plced during cervicl spine surgery [12]. In contrst, VCP fter open hert surgery were usully on the left side, result of the fct tht the left recurrent lryngel nerve psses cross the ortic rch. Neoplsm ccounts for 29.9 of the cses in this study. The most common neoplsm ws lung cncer in 34 ptients. All of these ptients hd unilterl VCP nd 24 ptients hd prlysis on the left side. This my be due to the longer intrthorcic portion of the left recurrent nerve thn on the right side. Esophgel nd brest cncer represented the second most common neoplsm. The most common cuse of metstsis ws distnt lung metstsis from brest cncer. In this study, there were 4 ptients with benign thyroid tumor developing VCP without surgery. Collzo-Clvell et l. [13] hve indicted tht 0.7 of ptients with benign thyroid neoplsms hve recurrent lryngel nerve prlysis. VCP is not only possible in benign neoplsms such s neurogenic tumors nd prgnglioms, but lso in benign thyroid tumor. Cses of idiopthic VCP hve no obvious cuses. 10 27 of reported cses in the English literture hve n idiopthic origin, wheres the Jpnese literture reports rte of 25.9 41.3 [1]. In our study, 10.7 of VCP ws idiopthic. The lower incidence of idiopthic VCP is uncertin nd my be due to the ptient popultion which ws hospitlized. Trum ws the cuse of VCP in 23 ptients (8), with intubtion injury being the most common cuse in 11 (3.8) of these. Intubtion-induced VCP ccounted for 7.1 11 of VCP in severl lrger series [1]. The mechnism could be the compression of the recurrent lryngel nerve by the lterl rytenoids, thyroid crtilge nd n inflted cuff from n endotrchel tube [1]. Mrie et l. [14] dvocted tht the recurrent lryngel nerve, fter intubtion, could suffer from virl infections triggered fter locl trum, such s herpes zoster. In ddition, trum cusing VCP my be due to trffic ccidents nd penetrtion of the neck. In ddition, we found rdition s the cuse of VCP in 10 ptients. Rdiotherpy is n effective nd commonly used tretment for hed nd neck cncer. However, rdiotherpy ffects both the tumor nd the surrounding norml tissues, nd dverse sequele my develop. Rdition-relted crnil nerve plsy secondry to fibrosis in the hed nd neck region, one of the rre lte complictions, hs been reported in vrious hed nd neck cncers, including the neck, tonsil, tongue bse, lrynx, hypophrynx nd nsophrynx. The hypoglossl nerve ws 170 ORL 2007;69:167 171 Chen /Jen /Wng /Lee /Lin
reported the most frequently ffected nerve fter irrdition for hed nd neck cncers, followed by the vgus nerve nd recurrent nerve. The most commonly reported hed nd neck cncers with rdition-relted VCP re those of the nsophrynx, tonsil nd tongue bse in decresing order [15 18]. In NPC, the reported frequencies of rdition-induced crnil nerve plsy rnge from 0.3 to 6 [19, 20]. Lee et l. [21] lso reported 0.6 incidence of rdition-induced VCP in NPC ptients secondry to vgus nerve involvement. The reson why ptients with NPC re more prone to crnil nerve plsy, including VCP, thn other hed nd neck cncer ptients my be the ntomic proximity of the nsophrynx to the skull bse, mking rdiotherpy to the crnil nerves inevitble. In mking dignosis of rdition-induced VCP, it is importnt to exclude ny other possible etiology. Crnil neuropthy in hed nd neck cncer ptients is fr more likely to be cused by tumor recurrence, regionl metstsis or second primry tumor thn by irrdition. The distinction between rdition-induced plsy nd tht due to true mlignncy is crucil. History, physicl exmintion, imging studies, endoscopy with biopsy nd observtion over time my led to correct dignosis. CNS disorders inducing VCP included Prkinson s disese, cerebrovsculr ccident nd skull bse tumors. Inflmmtory processes inducing VCP included pulmonry tuberculosis, rheumtoid rthritis nd pneumoconiosis. Other etiologies of crdiovsculr system diseses, so-clled Ortner s syndrome, include cor pulmonle, crdic tmponde nd rheumtic hert disese. Conclusion A surgicl process ws the most common cuse of VCP in hospitlized ptients, of which thyroid surgery ws the leding etiology in this study. In mles, the most common cuse ws neoplsm, wheres in femles it ws surgery. Before the cuse of recurrent lryngel nerve prlysis is lbeled idiopthic, the possibility of neoplsm must be ruled out. It is not only mlignnt but lso benign neoplsms, such s benign thyroid tumors, tht could cuse recurrent lryngel nerve plsy. In ddition, rdition-induced crnil nerve prlysis my occur in some hed nd neck cncers fter rdiotherpy. References 1 Myssiorek D: Recurrent lryngel nerve prlysis: ntomy nd etiology. Otolryngol Clin North Am 2004; 37: 25 44. 2 Benninger MS, Gillen JB, Altmn JS: Chnging etiology of vocl fold immobility. Lryngoscope 1998; 108: 1346 1350. 3 Rmdn HH, Wx MK, Avery S: Outcome nd chnging cuse of unilterl vocl cord prlysis. Otolryngol Hed Neck Surg 1998; 118: 199 202. 4 Terris DJ, Arnstein DP, Nguyen HH: Contemporry evlution of unilterl vocl cord prlysis. Otolryngol Hed Neck Surg 1992; 107: 84 90. 5 Yumoto E, Minod R, Hyodo M, Ymgt T: Cuses of recurrent lryngel nerve prlysis. Auris Nsus Lrynx 2002; 29: 41 45. 6 Feehery JM, Pribitkin EA, Heffelfinger RN, Lcombe VG, Lee D, Lowry LD, Kene WM, Stloff RT: The evolving etiology of bilterl vocl fold immobility. J Voice 2003; 17: 76 81. 7 Shei HG, Lin CZ, Zong BF: The etiologicl nlysis of vocl cord prlysis 300 cses review. Clin Med 1979; 3: 360 365. 8 Clerf LH: Unilterl vocl cord prlysis. JAMA 1953; 151: 900 903. 9 Prnell FW, Brndenburg JH: Vocl cord prlysis: review of 100 cses. Lryngoscope 1970; 80: 1036 1045. 10 Titche LL: Cuses of recurrent lryngel nerve prlysis. Arch Otolryngol 1976; 102: 259 261. 11 Tucker HM: Vocl cord prlysis 1979: etiology nd mngement. Lryngoscope 1980; 90: 585 590. 12 Ebrheim NA, Lu J, Skie M, Heck BE, Yesting RA: Vulnerbility of the recurrent lryngel nerve in the nterior pproch to the lower cervicl spine. Spine 1997; 22: 2664 2667. 13 Collzo-Clvell ML, Ghrib H, Mrgos NE: Reltionship between vocl cord prlysis nd benign thyroid disese. Hed Neck 1995; 17: 24 30. 14 Mrie JP, Keghin J, Mendel I, Gueit I, Dehesdin D, Andrieu-Guitrncourt J: Post-intubtion vocl cord prlysis: the virl hypothesis. A cse report. Eur Arch Otorhinolryngol 2001; 258: 285 286. 15 Lin YS, Jen YM, Lin JC: Rdition-relted crnil nerve plsy in ptients with nsophryngel crcinom. Cncer 2002; 95: 404 409. 16 Berger PS, Btini JP: Rdition-induced crnil nerve plsy. Cncer 1977; 40: 152 155. 17 Cheng VS, Schultz MD: Unilterl hypoglossl nerve trophy s lte compliction of rdition therpy of hed nd neck crcinom: report of four cses nd review of the literture on peripherl nd crnil nerve dmges fter rdition therpy. C ncer 1975; 35: 1537 1544. 18 Stern Y, Mrshk G, Shpitzer T, Segl K. Feinmesser R: Vocl cord plsy: possible lte compliction of rdiotherpy for hed nd neck cncer. Ann Otol Rhinol Lryngol 1995; 104: 294 296. 19 Flores AD, Dickson RI, Riding K, Coy P: Cncer of the nsophrynx in British Columbi. Am J Clin Oncol 1986; 9: 281 291. 20 Hoppe RT, Goffinet DR, Bgshw MA: Crcinom of the nsophrynx: eighteen yers experience with megvoltge rdition therpy. Cncer 1976; 37: 2605 2612. 21 Lee AW, Lw SC, Ng SH, Chn DK, Poon YF, Foo W, Tung SY, Cheung FK, Ho JH: Retrospective nlysis of nsophryngel crcinom treted during 1976 1985: lte complictions following megvoltge irrdition. Br J Rdiol 1992; 65: 918 928. Etiology of Vocl Cord Prlysis ORL 2007;69:167 171 171
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