eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Vocal Fold Paralysis, Bilateral: Workup

Author: Joel A Ernster, MD, Active Staff, Penrose-St Francis Healthcare System; Active Staff, Memorial Health System; Clinical Instructor, University of Colorado Health Sciences Center
Coauthor(s): Arturo Avila Chavez, MD, Assistant Professor, Department of Otolaryngology and Head and Neck Surgery, Instituto Nacional De Enfermedades Respiratorias of Mexico City; Douglas Skarada, MD, Consulting Staff, Department of Otolaryngology, Salem Hospital
Contributor Information and Disclosures

Updated: Sep 9, 2008

Workup

Laboratory Studies

  • Features of the history and clinical findings may suggest performance of the following studies:
    • Determination of serum K+ level
    • Determination of serum Ca+ level
    • Determination of glucose level
    • Antineutrophil cytoplasmic antibody (ANCA) test
    • Venereal disease research laboratory (VDRL) test
    • Determination of Lyme disease titer
    • Tuberculosis skin test
    • Uric acid test
    • Rheumatoid factor test
    • Antinuclear antibody (ANA) test
    • Determination of sedimentation rate

Imaging Studies

  • CT imaging along the entire length of the vagus nerve from the skull base to the superior mediastinum may be necessary when no other cause is identified.
  • MRI of the brain is not used as a routine study for bilateral vocal fold (cord) paralysis (BVFP).

Other Tests

  • Pulmonary function tests: Although diagnosis is based on clinical findings, results of pulmonary function tests performed with flow volume loops help support a diagnosis of upper airway obstruction. Also, they are used to provide an indicator of the severity of the obstruction and to monitor change after treatment.
  • Acoustic analysis: Voice quality usually is not significantly altered. Assessing the voice with acoustic analysis as a baseline test can be helpful in evaluating recovery over time.
  • Neurologic tests: In certain patients, a neurologist may perform a more thorough examination to assess central disorders or neuromuscular disorders that may result in bilateral vocal fold (cord) immobility (BVFI).

Diagnostic Procedures

  • Fiberoptic laryngoscopy
    • This procedure is the mainstay of clinical assessment.
    • Stroboscopic videolaryngoscopy may provide further information about vocal fold motion abnormalities when asymmetric mucosal wave patterns are identified.
    • Malingering or other psychogenic disorders may be identified by asking the patient to sniff or whistle, since these maneuvers work the abductors without the patient's volition.
  • Direct laryngoscopy
    • Examination of the posterior glottis and palpation of the arytenoid cartilages are essential steps in clarifying the nature of immobile vocal folds.
    • Cricoarytenoid (CA) joint ankylosis or IA scars that limit arytenoid motion are readily ascertained with direct laryngoscopy with the patient under general anesthesia and paralysis.
    • The subglottis, trachea, and main bronchi also may be examined to exclude subglottic stenosis, subtle infiltrative neoplasms, and other lesions along the entire airway.
  • Laryngeal EMG
    • Ideally, laryngeal EMG is used to assess both the TA and the PCA muscles, and it should be performed with local anesthesia rather than general anesthesia. It has been performed in anesthetized children.
    • The TA muscle is approached through the cricothyroid membrane, while the PCA muscle is approached percutaneously by rotating the larynx.
    • The glottic compromise caused by bilateral vocal fold immobility (BVFI) may render EMG hazardous. Therefore, waiting until after tracheostomy to perform the test may be prudent in some cases.
    • In evaluating a patient with bilateral vocal fold immobility (BVFI), EMG provides the potentially useful information in the following:
      • Differentiating between fixation and paralysis
      • Differentiating between neurapraxia and axonal transection
      • Determining the presence of neuromuscular disorders or peripheral neuropathy
    • In the recording the EMG, correct timing is essential. EMG can be performed as soon as 2 days after injury to aid in differential diagnosis. As a prognostic tool, a baseline EMG should be obtained at least 30 days after injury and a second one should be obtained 30-60 days after injury. After 6 months, laryngeal EMG should be used only to differentiate between fixation and paralysis and not to assess neural regeneration.

More on Vocal Fold Paralysis, Bilateral

Overview: Vocal Fold Paralysis, Bilateral
Workup: Vocal Fold Paralysis, Bilateral
Treatment: Vocal Fold Paralysis, Bilateral
Follow-up: Vocal Fold Paralysis, Bilateral
Multimedia: Vocal Fold Paralysis, Bilateral
References
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Further Reading

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Keywords

vocal, vocal fold paralysis, vocal cords, vocal cord, bilateral vocal fold paralysis, bilateral vocal cord paralysis, bilateral vocal cord immobility, vocal cord paralysis, bilateral vocal fold immobility, BVFP, BVFI, recurrent laryngeal nerve, cricoarytenoid joint, bilateral vocal fold

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Contributor Information and Disclosures

Author

Joel A Ernster, MD, Active Staff, Penrose-St Francis Healthcare System; Active Staff, Memorial Health System; Clinical Instructor, University of Colorado Health Sciences Center
Joel A Ernster, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Rhinologic Society, Colorado Medical Society, and Triological Society
Disclosure: Nothing to disclose.

Coauthor(s)

Arturo Avila Chavez, MD, Assistant Professor, Department of Otolaryngology and Head and Neck Surgery, Instituto Nacional De Enfermedades Respiratorias of Mexico City
Disclosure: Nothing to disclose.

Douglas Skarada, MD, Consulting Staff, Department of Otolaryngology, Salem Hospital
Disclosure: Nothing to disclose.

Medical Editor

Clark A Rosen, MD, Director, University of Pittsburgh Voice Center; Associate 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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, 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 unstricted 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

 
 
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