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Prospective study to assess vocal cord palsy investigations
Otolaryngology–Head and Neck Surgery (2008) 138, 788-790
SHORT SCIENTIFIC COMMUNICATION
Prospective study to assess vocal cord palsy investigations Mohamed Reda El Badawey, FRCS (Ed), FRCS (ORL HNS), MD, Samad Punekar, MBBS, MRCP (UK), and Ivan Zammit-Maempel, MBChB (Hons), MRCP, FRCR, Newcastle upon Tyne, UK OBJECTIVES: To assess the investigation and clinical outcome of patients presenting with unexplained vocal cord palsy (VCP). STUDY DESIGN AND METHODS: A prospective cohort study designed to evaluate 86 patients with unexplained VCP presenting to our tertiary referral center. RESULTS: Twenty-four (36%) patients had positive findings on CT scanning. Twenty-one (24%) cases showed mediastinal adenopathy ⫾ pulmonary mass. The other three cases were a thoracic aneurysm, prostatic metastasis below the skull base, and a postcricoid tumor. Follow-up period was 18 to 66 months. Fifteen (24%) of the 62 patients with negative radiology recovered full vocal cord movement. CONCLUSION: CT neck ⫾ chest plays an important role in the evaluation of VCP patients. The majority of pertinent radiologic findings involve malignant neoplasm. © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
T
here is a lack of consensus regarding the choice of investigations for vocal cord paralysis (VCP). Different centers advocate a battery of investigations for unexplained VCP that puts extra burdens on health service resources.1 The etiology of VCP is varied and is usually due to a lesion of, or adjacent to, the vagus nerve or its recurrent laryngeal branch. VCP could be the first presenting sign of a neoplastic lesion; therefore, it is a priority to exclude these lesions.2,3 The aim of this study was to assess the investigations and clinical outcome of patients presenting with unexplained VCP.
MATERIAL AND METHODS We designed a prospective cohort study recruiting all patients presenting with VCP referred for CT scanning between May 2001 and May 2005. The study was approved by the Institutional Review Board.
Any patient with a laryngeal or obvious hypopharyngeal tumor or postoperative VCP was excluded from the study. Eighty-six patients were included and evaluated by thorough medical history and full ENT examination including fibro-optic flexible laryngoscopy. All negative radiology patients were followed up by the relevant clinical team for a minimum of 18 months. All patients were scanned on a 4-slice Volume Zoom CT scanner (Siemens, Erlangen, Germany) with 3-mm slice thickness in the neck and 5-mm thickness in the chest, following intravenous contrast. Patients with right VCP had a CT from the skull base to the lung apex while patients with left VCP had CT from skull base to diaphragm. Other relevant investigations such as routine blood tests, panendoscopy, and any biopsy results, as well as the clinical course including recovery of the VCP and/or voice, were documented.
RESULTS There was an equal sex distrubution in the 86 patients, with an age range of 26 to 89 years (median, 65.8 years). Fiftyone had left, 31 right, and four had bilateral VCP.
Positive Radiology Patients Twenty-four patients had relevant CT abnormalities with a side distribution as shown in Figure 1. The most common malignant disease presenting with VCP as a first sign of the disease was bronchogenic carcinoma (Fig 2). Fifteen out of the 24 patients had positive histology including 10 bronchogenic, two esophageal, and one postcricoid carcinoma; one Hodgkin’s lymphoma, and one metastatic breast carcinoma. One patient had an aortic arch aneurysm. Of the remaining eight patients with no histologic diagnosis, five were presumed to be bronchogenic carcinoma,
Received August 10, 2007; revised February 20, 2008; accepted March 4, 2008.
0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2008.03.004
ElBadawey et al
Prospective study to assess vocal . . .
789
two metastatic breast carcinoma, and one metastatic prostate cancer. Fifteen of the 23 patients with malignancy died. Only nine patients of the positive CT scan group had a chest x-ray (CXR), of which three were abnormal. Four CXRs were normal despite an abnormal CT chest. The remaining two patients with a normal CXR had neck lesions.
Negative Radiology Patients All 62 patients had regular six-monthly clinical evaluation including flexible laryngoscopy. All the patients in this group were referred for speech therapy and received further evaluation using strobolaryngoscopy. Thirty patients (48%) had satisfactory voice recovery after 6 months. Fifteen of these 62 patients (24%) had full recovery of the vocal cord (VC) movements within 9 months. Panendoscopy was performed on 20 patients in this group, without revealing any pathology. Therefore it had not changed the treatment plan for these patients. Further investigations did not show any positive findings to explain the etiology of the VCP. Four of the 62 patients died of unrelated causes.
DISCUSSION Several previous studies have demonstrated that VCP is more common on the left. Malignancy as a cause for the VCP accounted for 24.7 percent to 40.5 percent of the patients.2,4,5 Our study showed an incidence of 26.7 percent (23/86), with underlying neoplasm, usually pulmonary. Spontaneous recovery of VC function varied between 16 percent and 24 percent of patients in previous studies.2,4 In our study 24 percent of patients with negative radiology had full spontaneous recovery of VC movement at 9 months. Laryngeal EMG was not performed as it is not a routine test in our center. Benninger et al’s investigation policy4 included routine CXR and CT neck ⫾ chest and MRI of the head and chest, endoscopy, barium swallow, and metabolic studies when specifically indicated. Terris et al5 found that
Figure 2 Inoperable bronchogenic tumor with mediastinal lymph node metastasis.
CXR was the most useful test, yielding the diagnosis in 13 cases out of 24, but pointed out the limitations of CXR. Not all patients in our study had a CXR prior to CT, but of those with positive thoracic CT findings, the usefulness of CXR was extremely variable. Liu et al1 estimated the economic consequences of investigating 49 patients with VCP by MRI and CT. These patients were divided into high-suspicion and low-suspicion groups based on other clinical abnormality. They found the average cost of finding space-occupying lesions as a cause of VCP to be more than 4.5 times higher in patients without suspicious antecedent clinical findings ($10,849). In our study, no patient subsequently presented with any pathology following a negative CT after a follow-up period ranging from 18 to 66 months. Terris et al5 also emphasized the point that in no instance was a malignancy discovered subsequent to the initial examinations in their study. Panendoscopy was essential in a few of the positive CT scan patients to obtain a biopsy and confirm the extent of the tumor. In our study, panendoscopy was not useful in negative CT patients.
CONCLUSION
Figure 1 Distribution of positive and negative radiology according to side of VCP.
Our CT scan protocol for unexplained vocal cord paralysis is efficient to detect any significant neoplastic pathology. The majority of patients with positive radiology have a malignant cause. Clinical follow-up, further evaluation, and the role of the intervention should be directed by the clinical course.
790
Otolaryngology–Head and Neck Surgery, Vol 138, No 6, June 2008
AUTHOR INFORMATION
FINANCIAL DISCLOSURE
From Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK.
None.
Accepted for presentation at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Washington, DC, September 16-19, 2007. Corresponding author: Mohamed Reda ElBadawey, FRCS (Ed), FRCS (ORL HNS), MD, Consultant Otolaryngologist, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK. E-mail address: [email protected].
AUTHOR CONTRIBUTIONS Mohamed Reda ElBadawey, study design, data collection, analysis, manuscript writing, and submitting the paper to the AAO-HNS annual meeting; Samad Punekar, data collection; Ivan Zammit-Maempel, study design, data collection, analysis, manuscript writing.
REFERENCES 1. Liu AY, Yousem DM, Chalian AA, et al. Economic consequences of diagnostic imaging for vocal cord paralysis. Acad Radiol 2001;8:137– 48. 2. Ramadan HH, Wax MK, Avery S. Outcome and changing cause of unilateral vocal cord paralysis. Otolaryngol Head Neck Surg 1998;118: 199 –202. 3. Robinson S, Pitkaranta A. Radiology findings in adult patients with vocal fold paralysis. Clin Radiol 2006;61:863–7. 4. Benninger MS, Gillen JB, Altman JS. Changing etiology of vocal fold immobility. Laryngoscope 1998;108:1346 –50. 5. Terris DJ, Arnstein DP, Nguyen HH. Contemporary evaluation of unilateral vocal cord paralysis. Otolaryngol Head Neck Surg 1992;107: 84 –90.
SHORT SCIENTIFIC COMMUNICATION
Prospective study to assess vocal cord palsy investigations Mohamed Reda El Badawey, FRCS (Ed), FRCS (ORL HNS), MD, Samad Punekar, MBBS, MRCP (UK), and Ivan Zammit-Maempel, MBChB (Hons), MRCP, FRCR, Newcastle upon Tyne, UK OBJECTIVES: To assess the investigation and clinical outcome of patients presenting with unexplained vocal cord palsy (VCP). STUDY DESIGN AND METHODS: A prospective cohort study designed to evaluate 86 patients with unexplained VCP presenting to our tertiary referral center. RESULTS: Twenty-four (36%) patients had positive findings on CT scanning. Twenty-one (24%) cases showed mediastinal adenopathy ⫾ pulmonary mass. The other three cases were a thoracic aneurysm, prostatic metastasis below the skull base, and a postcricoid tumor. Follow-up period was 18 to 66 months. Fifteen (24%) of the 62 patients with negative radiology recovered full vocal cord movement. CONCLUSION: CT neck ⫾ chest plays an important role in the evaluation of VCP patients. The majority of pertinent radiologic findings involve malignant neoplasm. © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
T
here is a lack of consensus regarding the choice of investigations for vocal cord paralysis (VCP). Different centers advocate a battery of investigations for unexplained VCP that puts extra burdens on health service resources.1 The etiology of VCP is varied and is usually due to a lesion of, or adjacent to, the vagus nerve or its recurrent laryngeal branch. VCP could be the first presenting sign of a neoplastic lesion; therefore, it is a priority to exclude these lesions.2,3 The aim of this study was to assess the investigations and clinical outcome of patients presenting with unexplained VCP.
MATERIAL AND METHODS We designed a prospective cohort study recruiting all patients presenting with VCP referred for CT scanning between May 2001 and May 2005. The study was approved by the Institutional Review Board.
Any patient with a laryngeal or obvious hypopharyngeal tumor or postoperative VCP was excluded from the study. Eighty-six patients were included and evaluated by thorough medical history and full ENT examination including fibro-optic flexible laryngoscopy. All negative radiology patients were followed up by the relevant clinical team for a minimum of 18 months. All patients were scanned on a 4-slice Volume Zoom CT scanner (Siemens, Erlangen, Germany) with 3-mm slice thickness in the neck and 5-mm thickness in the chest, following intravenous contrast. Patients with right VCP had a CT from the skull base to the lung apex while patients with left VCP had CT from skull base to diaphragm. Other relevant investigations such as routine blood tests, panendoscopy, and any biopsy results, as well as the clinical course including recovery of the VCP and/or voice, were documented.
RESULTS There was an equal sex distrubution in the 86 patients, with an age range of 26 to 89 years (median, 65.8 years). Fiftyone had left, 31 right, and four had bilateral VCP.
Positive Radiology Patients Twenty-four patients had relevant CT abnormalities with a side distribution as shown in Figure 1. The most common malignant disease presenting with VCP as a first sign of the disease was bronchogenic carcinoma (Fig 2). Fifteen out of the 24 patients had positive histology including 10 bronchogenic, two esophageal, and one postcricoid carcinoma; one Hodgkin’s lymphoma, and one metastatic breast carcinoma. One patient had an aortic arch aneurysm. Of the remaining eight patients with no histologic diagnosis, five were presumed to be bronchogenic carcinoma,
Received August 10, 2007; revised February 20, 2008; accepted March 4, 2008.
0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved. doi:10.1016/j.otohns.2008.03.004
ElBadawey et al
Prospective study to assess vocal . . .
789
two metastatic breast carcinoma, and one metastatic prostate cancer. Fifteen of the 23 patients with malignancy died. Only nine patients of the positive CT scan group had a chest x-ray (CXR), of which three were abnormal. Four CXRs were normal despite an abnormal CT chest. The remaining two patients with a normal CXR had neck lesions.
Negative Radiology Patients All 62 patients had regular six-monthly clinical evaluation including flexible laryngoscopy. All the patients in this group were referred for speech therapy and received further evaluation using strobolaryngoscopy. Thirty patients (48%) had satisfactory voice recovery after 6 months. Fifteen of these 62 patients (24%) had full recovery of the vocal cord (VC) movements within 9 months. Panendoscopy was performed on 20 patients in this group, without revealing any pathology. Therefore it had not changed the treatment plan for these patients. Further investigations did not show any positive findings to explain the etiology of the VCP. Four of the 62 patients died of unrelated causes.
DISCUSSION Several previous studies have demonstrated that VCP is more common on the left. Malignancy as a cause for the VCP accounted for 24.7 percent to 40.5 percent of the patients.2,4,5 Our study showed an incidence of 26.7 percent (23/86), with underlying neoplasm, usually pulmonary. Spontaneous recovery of VC function varied between 16 percent and 24 percent of patients in previous studies.2,4 In our study 24 percent of patients with negative radiology had full spontaneous recovery of VC movement at 9 months. Laryngeal EMG was not performed as it is not a routine test in our center. Benninger et al’s investigation policy4 included routine CXR and CT neck ⫾ chest and MRI of the head and chest, endoscopy, barium swallow, and metabolic studies when specifically indicated. Terris et al5 found that
Figure 2 Inoperable bronchogenic tumor with mediastinal lymph node metastasis.
CXR was the most useful test, yielding the diagnosis in 13 cases out of 24, but pointed out the limitations of CXR. Not all patients in our study had a CXR prior to CT, but of those with positive thoracic CT findings, the usefulness of CXR was extremely variable. Liu et al1 estimated the economic consequences of investigating 49 patients with VCP by MRI and CT. These patients were divided into high-suspicion and low-suspicion groups based on other clinical abnormality. They found the average cost of finding space-occupying lesions as a cause of VCP to be more than 4.5 times higher in patients without suspicious antecedent clinical findings ($10,849). In our study, no patient subsequently presented with any pathology following a negative CT after a follow-up period ranging from 18 to 66 months. Terris et al5 also emphasized the point that in no instance was a malignancy discovered subsequent to the initial examinations in their study. Panendoscopy was essential in a few of the positive CT scan patients to obtain a biopsy and confirm the extent of the tumor. In our study, panendoscopy was not useful in negative CT patients.
CONCLUSION
Figure 1 Distribution of positive and negative radiology according to side of VCP.
Our CT scan protocol for unexplained vocal cord paralysis is efficient to detect any significant neoplastic pathology. The majority of patients with positive radiology have a malignant cause. Clinical follow-up, further evaluation, and the role of the intervention should be directed by the clinical course.
790
Otolaryngology–Head and Neck Surgery, Vol 138, No 6, June 2008
AUTHOR INFORMATION
FINANCIAL DISCLOSURE
From Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK.
None.
Accepted for presentation at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Washington, DC, September 16-19, 2007. Corresponding author: Mohamed Reda ElBadawey, FRCS (Ed), FRCS (ORL HNS), MD, Consultant Otolaryngologist, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK. E-mail address: [email protected].
AUTHOR CONTRIBUTIONS Mohamed Reda ElBadawey, study design, data collection, analysis, manuscript writing, and submitting the paper to the AAO-HNS annual meeting; Samad Punekar, data collection; Ivan Zammit-Maempel, study design, data collection, analysis, manuscript writing.
REFERENCES 1. Liu AY, Yousem DM, Chalian AA, et al. Economic consequences of diagnostic imaging for vocal cord paralysis. Acad Radiol 2001;8:137– 48. 2. Ramadan HH, Wax MK, Avery S. Outcome and changing cause of unilateral vocal cord paralysis. Otolaryngol Head Neck Surg 1998;118: 199 –202. 3. Robinson S, Pitkaranta A. Radiology findings in adult patients with vocal fold paralysis. Clin Radiol 2006;61:863–7. 4. Benninger MS, Gillen JB, Altman JS. Changing etiology of vocal fold immobility. Laryngoscope 1998;108:1346 –50. 5. Terris DJ, Arnstein DP, Nguyen HH. Contemporary evaluation of unilateral vocal cord paralysis. Otolaryngol Head Neck Surg 1992;107: 84 –90.