Unilateral Vocal Fold Paralysis Workup

  • Author: Thomas L Carroll, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Sep 27, 2011
 

Imaging Studies

  • Although rarely obtained today for the workup of unilateral vocal fold paralysis (UVFP), chest radiography can be the first screening evaluation for a patient with unilateral vocal fold paralysis (UVFP) of unknown etiology. This may reveal a chest malignancy as the cause of the unilateral vocal fold paralysis (UVFP). A Pancoast tumor, mediastinal mass, or even massive cardiomegaly may be found. The latter has rarely been shown to be a cause of unilateral vocal fold paralysis (UVFP) when enlargement of the left atrium that causes a stretch injury to the left recurrent laryngeal nerve is present.
  • CT scanning or MRI of the path of the vagus/recurrent laryngeal nerve
    • CT scanning or MRI should be performed as part of a workup for a unilateral vocal fold paralysis (UVFP) of unknown etiology. The imaging should include the entire path of the vagus/recurrent laryngeal nerve involved. A left unilateral vocal fold paralysis (UVFP) involves imaging from the base of skull to the mid chest (arch of the aorta). The right unilateral vocal fold paralysis (UVFP) evaluation should extend from the base of the skull to the clavicle.
    • Although CT is usually the test of choice, the decision between CT scanning and MRI is personal and can be decided by the otolaryngologist and radiologist.
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Other Tests

  • Voice evaluation: Voice evaluation by a speech-language pathologist is often helpful to determine the degree of maladaptive compensatory behavior present. In addition, voice recording provides documentation of the baseline voice quality and ability. This is important because treatment for the vocal fold paralysis usually begins shortly after evaluation. Often, this voice evaluation includes an objective analysis of the voice quality of the patient, including acoustic and aerodynamic analysis (air flow and laryngeal efficiency) of speech production.
  • Laryngeal electromyography (LEMG)
    • LEMG is an electrophysiologic evaluation of the muscles of the larynx. This test is performed using an EMG needle percutaneously under local or no anesthesia. The LEMG most often involves an evaluation of the thyroarytenoid/lateral cricoarytenoid muscle complex, which is reflective of the recurrent laryngeal nerve innervation and the cricothyroid muscle, which is indicative of the superior laryngeal nerve status/function.
    • LEMG findings can be diagnostic and prognostic and can therefore be a useful tool to guide therapy. LEMG can be used to differentiate between vocal fold immobility caused by cricoarytenoid joint pathology and that caused by vocal fold paralysis. The timing of LEMG is crucial in accurately determining the prognosis of spontaneous recovery of the paralyzed vocal fold. LEMG is most predictive of outcome if performed 6 weeks to 6 months after the onset of symptoms. LEMG can shorten the time until permanent treatment is implemented, subsequently reducing the time of the patient's dysphonia and the number of temporary treatments required.
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Contributor Information and Disclosures
Author

Thomas L Carroll, MD  Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Tufts University School of Medicine and Director, The Center for Voice and Swallowing, Tufts Medical Center

Thomas L Carroll, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American Laryngological Association, and American Medical Association

Disclosure: Merz aesthetics inc. Consulting fee Speaking and teaching

Coauthor(s)

Clark A Rosen, MD  Director, University of Pittsburgh Voice Center; Professor, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh School of Medicine

Clark A Rosen, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Pennsylvania Medical Society

Disclosure: Bioform Medical Consulting fee Consulting; Bioform Medical Consulting fee Speaking and teaching

Ryan J Soose, MD  Director, Division of Sleep Surgery, Assistant Professor, Department of Otolaryngology, University of Pittsburgh Medical Center

Ryan J Soose, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Sleep Medicine, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

John Schweinfurth, MD  Professor, Department of Otolaryngology, University of Mississippi Medical Center

John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Laryngological Association, American Medical Association, and Triological Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert M Kellman, MD  Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society

Disclosure: GE Healthcare Honoraria Review panel membership; Revent Medical Honoraria Review panel membership

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

Additional Contributors

Medscape Reference thanks Vijay R Ramakrishnan, MD, Assistant Professor, Department of Otolaryngology, University of Colorado School of Medicine, for assistance with the video contribution to this article.

References

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Preoperatively, the arrow demonstrates the paralyzed vocal fold, which is characteristically foreshortened, lateralized, and flaccid.
Postoperatively, the image shows the same vocal fold as the image above following laryngeal framework surgery (arytenoids adduction and medialization laryngoplasty). The left vocal fold is now midline and has improved length.
Vocal fold paralysis, presurgery.
Vocal fold paralysis, postsurgery.
This patient was evaluated for hoarseness. One can appreciate immobility of the left true vocal fold. Stroboscopy in the second portion of the video shows the mucosal wave only with patient effort. Video courtesy of Vijay R Ramakrishnan, MD.
 
 
 
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