Bilateral Vocal Fold Immobility (BVFI)

Definitions

  • Bilateral Vocal Fold Immobility (BVFI): refers to all etiologies of decreased vocal cord movement
  • Bilateral Vocal Cord Paralysis (BVCP): refers to the neurologic etiologies of BVFI (ie: those that involve the vagus nerve or its distal branches, the recurrent laryngeal nerves)

Anatomy

  • Nucleus Ambiguus of the Medulla Oblongata Gives Rise to Vagus Nerve
    • Vagus enters the jugular foramen (along with the accessory nerve and jugular vein): within jugular foramen, forms the superior ganglion (contains the cell bodies of the sensory component of the nerve, which provide sensation to the ear canal skin, via the Arnold nerve)
    • Vagus nerve exits the jugular foramen to form the nodose ganglion (contains the cell bodies which mediate the sensory or visceral afferents from the larynx and pharynx)
    • Superior laryngeal nerve arises from vagus and enters the larynx through the thyrohyoid membrane
    • Right recurrent laryngeal nerve arises from the vagus nerve and loops posteriorly around the subclavian artery to enter the larynx through the Killian-Jamieson area or superior to the fibers of the cricopharyngeal muscle entering the larynx at the cricothyroid space
    • Left recurrent laryngeal nerve arises from the vagus nerve as it crosses anterior to the aorta and lateral to the ligamentum arteriosum (remnant of the patent ductus arteriosum between the aorta and the pulmonary vein) -> courses superiorly to enter the larynx opposite the right recurrent laryngeal nerve

Epidemiology

Incidence of Etiologies of Unilateral Vocal Fold Immobility (1996-2005 data per [MEDLINE])

  • Surgery (46.3% of cases)
    • Thyroid Surgery (26% of all surgical cases)
    • Other Surgery (17% of all surgical cases)
    • Anterior Cervical Spine Surgery (15% of all surgical cases)
    • Carotid Endarterectomy (11% of all surgical cases)
    • Lung Biopsy/Resection (8% of all surgical cases)
    • Parathyroid Surgery (6% of all surgical cases)
    • Intracranial Surgery (5% of all surgical cases)
    • Aortic Aneurysm Surgery (5% of all surgical cases)
    • Heart Valve Surgery (4% of all surgical cases)
    • Skull Base Surgery: accounts for 2% of all surgical cases)
    • Thyroid and Parathyroid Surgery, Combined (1% of all surgical cases)
  • Idiopathic (17.6% of cases)
  • Malignancy (13.5% of cases)
    • Lung Cancer (6.6% of cases)
    • Metastatic Cancer (3.3% of cases)
    • Thyroid Cancer (2.2% of cases)
    • Other Cancer (0.8% of cases)
    • Esophageal Cancer (0.6% of cases)
  • Other (5.2% of cases)
  • Intubation (4.4% of cases)
  • Infection (3.6% of cases)
  • Central Nervous System Disease (3.0% of cases)
  • Trauma (2.2% of cases)
  • Inflammation (1.9% of cases)

Incidence of Etiologies of Bilateral Vocal Fold Immobility (1996-2005 data per [MEDLINE])

  • Surgery (55.6% of cases)
    • Thyroid Surgery (48% of all all surgical cases)
    • Thyroid and Parathyroid Surgery, Combined (13% of all surgical cases)
    • Parathyroid Surgery (29% of all surgical cases)
    • Carotid Endarterectomy (5% of all surgical cases)
    • Heart Surgery (5% of all surgical cases)
  • Malignancy (9.7% of cases)
    • Lung Cancer (4.2% of cases)
    • Metastatic Cancer (2.8% of cases)
    • Other Cancer (1.4% of cases)
    • Esophageal Cancer (1.4% of cases)
    • Thyroid Cancer (0% of cases)
  • Intubation (9.7% of cases)
  • Idiopathic (8.3% of cases)
  • Central Nervous System Disease/Neuropathy (6.9% of cases)
  • Stenosis (2.8% of cases)
  • Infection (1.4% of cases)
  • Inflammation (1.4% of cases)
  • Trauma (1.4% of cases)
  • Radiation (1.4% of cases)
  • Other (1.4% of cases)

Etiology

Cricoarytenoid Arthritis (see Cricoarytenoid Arthritis, [[Cricoarytenoid Arthritis]])

Primary Rheumatologic Disease

Other

  • Cricoarytenoid Joint Ankylosis Due to Prior Streptococcus Infection (see Streptococcus, [[Streptococcus]])
  • Crohn’s Disease (see Crohn’s Disease, [[Crohns Disease]])
  • Mumps-Associated Laryngeal Arthritis (see Mumps Virus, [[Mumps Virus]])
  • Radiation Therapy Injury to Cricoarytenoid Joint (see Radiation Therapy, [[Radiation Therapy]])
  • External Trauma to Cricoarytenoid Joint
  • Internal Trauma Due to Endotracheal Tube-Related Injury to Cricoarytenoid Joint: includes posterior or anterior arytenoid displacement, posterior dislocation resulting from extubation with a partially inflated endotracheal tube cuff, arytenoid chondritis secondary to prolonged endotracheal intubation
  • Tietze’s Syndrome

Laryngeal Inflammation

Laryngospasm (see Laryngospasm, [[Laryngospasm]])

Neurologic Disease/Dysfunction Involving the Vocal Folds

  • Alport Syndrome (see Alport Syndrome, [[Alport Syndrome]]): case report invoved a patient with chronic kidney disease, post-op from surgery with high amount of blood loss and possible impaired perfusion to recurrent laryngeal nerves (with ischemic injury) during the case
  • Altered Mental Status with Inability to Protect Upper Airway: typically acute
  • Amyotrophic Lateral Sclerosis (ALS) (see Amyotrophic Lateral Sclerosis, [[Amyotrophic Lateral Sclerosis]])
  • Arnold-Chiari Malformation
  • Charcot-Marie-Tooth Disease
  • Creutzfeldt-Jacob Disease (CJD) (see Creutzfeldt-Jacob Disease, [[Creutzfeldt-Jacob Disease]])
  • Diabetes Mellitus (DM) (see Diabetes Mellitus, [[Diabetes Mellitus]])
    • Physiology: neuropathy involving the laryngeal nerves
  • Dystonic Reaction of Pharyngeal+Laryngeal Muscles (see Dystonic Reaction of Pharyngeal+Laryngeal Muscles, [[Dystonic Reaction of Pharyngeal+Laryngeal Muscles]]): typically acute
  • Essential Tremor (see Essential Tremor, [[Essential Tremor]]): typically mild upper airway obstruction
  • Hydrocephalus (see Hydrocephalus, [[Hydrocephalus]])
  • Hypocalcemia (see Hypocalcemia, [[Hypocalcemia]])
  • Hypokalemia (see Hypokalemia, [[Hypokalemia]])
  • Hypokalemic Periodic Paralysis (see Hypokalemic Periodic Paralysis, [[Hypokalemic Periodic Paralysis]])
  • Idiopathic Bilateral Vocal Cord Paralysis
  • Laryngeal/Tracheal Fracture (see Tracheobronchial Fracture, [[Tracheobronchial Fracture]]): with recurrent laryngeal nerve injury
  • Lyme Disease (see Lyme Disease, [[Lyme Disease]])
    • Physiology: neuropathy involving the laryngeal nerves
  • Mediastinal Mass/Lymphadenopathy (see Mediastinal Mass, [[Mediastinal Mass]]): in cases where large mass or nodes impact the recurrent laryngeal nerves
  • Meningomyelocele
  • Mobius Syndrome
  • Myasthenia Gravis (see Myasthenia Gravis, [[Myasthenia Gravis]])
  • Paclitaxel (Taxol) (see Paclitaxel, [[Paclitaxel]])
    • Physiology: neuropathy involving the laryngeal nerves
  • Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction) (see Paradoxical Vocal Fold Motion, [[Paradoxical Vocal Fold Motion]]): typically acute
  • Parkinson’s Disease (see Parkinson’s Disease, [[Parkinsons Disease]]): may be acute (particularly in the post-operative setting) or progressive
  • Postpolio Syndrome (see Poliomyelitis, [[Poliomyelitis]])
  • Rheumatoid Arthritis (RA) (see Rheumatoid Arthritis, [[Rheumatoid Arthritis]]): due to arteritis of vasa vasorum of recurrent laryngeal (and vagus) nerves
    • Physiology: arteritis of vasa vasorum of recurrent laryngeal (and vagus) nerves
  • Scorpion Sting (see Scorpion Sting, [[Scorpion Sting]])
    • Centuroides Exilicauda (Sculpuratus)
    • Centuroides Suffusus
  • Shy-Drager Syndrome
  • Synkinesis of the Recurrent Laryngeal Nerve
  • Systemic Lupus Erythematosus (SLE) (see Systemic Lupus Erythematosus, [[Systemic Lupus Erythematosus]])
    • Physiology: neuropathy involving the laryngeal nerves
  • Vincristine (see Vincristine, [[Vincristine]])
    • Physiology: neuropathy involving the laryngeal nerves

Developmental Abnormality or Neoplasm the Involving Vocal Folds

  • Angioma
  • Carcinoma
  • Cervical Node Metastases: extrinsic compression of upper airway
  • Chondroma
  • Chondrosarcoma
  • Congenital Laryngeal Malformation
  • Cystic Hygroma
  • Granuloma
  • Histiocytoma
  • Lymphoma (see Lymphoma, [[Lymphoma]])
  • Papilloma
  • Polyp
  • Rhabdomyosarcoma (see Rhabdomyosarcoma, [[Rhabdomyosarcoma]])
  • Thyroid Cancer (see Thyroid Cancer, [[Thyroid Cancer]])
  • Tracheal Adenoid Cystic Carcinoma (see Adenoid Cystic Carcinoma, [[Adenoid Cystic Carcinoma]])

Intubation Injury to Vocal Folds

Acute

  • Arytenoid Dislocation
  • Excessive Endotracheal Tube Cuff Pressure with Compression of Recurrent Laryngeal Nerve Where It Enters the Larynx
  • Hyperextension of Neck with Vagus Nerve Injury
  • Larygneal Mask Airway (LMA)-Related Injury
  • Recurrent Laryngeal Nerve Injury Due to Anterior Thyroid Cartilage Displacement (Relative to the Cricoid Cartilage)

Chronic

  • Excessive Endotracheal Tube Cuff Pressure with Compression of Recurrent Laryngeal Nerve Where It Enters the Larynx
  • Posterior Glottic Stenosis (PGS): due to prolonged or traumatic intubation
  • Vocal Cord Granuloma

Mechanical/Iatrogenic Injury to Vocal Folds

  • Nasogastric Tube Syndrome (see Nasogastric Tube Syndrome, [[Nasogastric Tube Syndrome]]): first reported in 1981, it is believed to be due to paresis of the posterior cricoarytenoid muscles secondary to ulceration and infection over the posterior lamina of the cricoid
    • Risk Group: diabetic renal transplant patients (due to prolonged gastroparesis and requirement for nasogastric tube drainage)
  • Proximal Esophageal Stent Placement
  • Radiation-Induced Injury
    • Radiation Injury to Vocal Cords (see Radiation Therapy, [[Radiation Therapy]])
    • Radiation Injury to Cricoarytenoid Joint (see Radiation Therapy, [[Radiation Therapy]]): see Cricoarytenoid Arthritis above
    • Chondronecrosis

Surgical Injury to Vocal Folds

  • Anterior Cervical Disk Surgery: typically results in unilateral injury (which may compromise the upper airway if contralateral side was previously injured)
  • Brainstem Surgery: may result in bilateral injury
  • Cardiac Surgery
  • Carotid Endarterectomy: typically results in unilateral injury (which may compromise the upper airway if contralateral side was previously injured)
  • Endolaryngeal Surgery (Using CO2 Laser): may injur posterior glottis
  • Esophageal Surgery: may result in bilateral injury
  • Thyroid Surgery (accounts for 48% of all surgical cases): may result in bilateral injury
  • Parathyroid Surgery: may result in bilateral injury
  • Tracheal Surgery: may result in bilateral injury

Diagnosis

  • Pulmonary Function Tests (PFT’s)
    • Bilateral Vocal Cord Paralysis
      • PEFR: decreased
      • FEV1: decreased
      • MVV: decreased
      • Inspiratory flow rates: decreased
      • FIF50/FEF50 ratio: ratio <1 suggests variable extrathoracic obstruction
      • Flow-volume loop: flattened inspiratory limb (indicating variable extrathoracic obstruction)
  • CXR/Chest CT Pattern: normal CXR
  • Fiberoptic Bronchoscopy: reveals paralyzed cords
    • Airway Diameter <8 mm: sufficient to produce exertional dyspnea
    • Airway Diameter <5 mm: sufficient to produce stridor
  • Fiberoptic Laryngoscopy
    • Bilateral Vocal Cord Paralysis: cords move toward midline (due to intact action of cricothyroid muscles with injured recurrent laryngeal nerves)
  • Laryngeal Electromyogram (EMG)

Clinical Manifestations

General Findings

  • Aspiration (see Aspiration Pneumonia, [[Aspiration Pneumonia]])
  • Breathy Voice: variable
  • Change in Voice
  • Stridor (see Stridor, [[Stridor]]): variable

Specific Findings in Bilateral Vocal Cord Paralysis

  • Absence of Hoarseness with Normal/Near Normal Voice: hoarseness is usually minimal with bilateral vocal cord paralysis, since both cords are in midline (weakly adducted) position and vibrate passively with phonation and expiration
  • Cough (with Barking Quality) (see Cough, [[Cough]])
  • Exertional Dyspnea (see Dyspnea, [[Dyspnea]]): occurs when airway diameter is <8 mm
    • May not occur until 10-20 years later
  • Inability to Clear Secretions
  • Inspiratory Stridor (see Stridor, [[Stridor]]): when airway diameter is <5 mm
    • During forced inspiration
    • May be present at rest and increase during quick or forced inspiration
  • Respiratory Failure (see Respiratory Failure, [[Respiratory Failure]])
  • Wheezing (see Obstructive Lung Disease, [[Obstructive Lung Disease]]): particularly with exertion

Treatment

  • Tracheostomy: may be required

References

  • Changing etiology of vocal fold immobility. Laryngoscope 1998;108(9):1346-1350 [MEDLINE]
  • The nasogastric tube syndrome. Laryngoscope. 1990 Sep;100(9):962-8 [MEDLINE]
  • Bilateral vocal fold paralysis caused by familial hypokalemic periodic paralysis. Otolaryngol Head Neck Surg. 1999 May;120(5):785-6 [MEDLINE]
  • Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope. 2007 Oct;117(10):1864-70 [MEDLINE]
  • Bilateral vocal cord paralysis in a patient with chronic renal failure associated with Alport syndrome. Journal of Anesthesia June 2010, Volume 24, Issue 3, pp 472-475 [MEDLINE]
  • Bilateral Vocal Cord Palsy as the Sole Presentation of Acquired Syphilis. Malays J Med Sci. 2010 Apr-Jun; 17(2): 56–60 [MEDLINE]