Brake and Anderson Journal of Otolaryngology - Head and Neck Surgery

(2015) 44:27
DOI 10.1186/s40463-015-0080-8

ORIGINAL RESEARCH ARTICLE

Open Access

Bilateral vocal fold immobility: a 13 year

review of etiologies, management and the
utility of the empey index
Maria K. Brake1 and Jennifer Anderson2*

Abstract
Background: Bilateral vocal fold immobility (BVFI) is a rare diagnosis causing dyspnea, dysphonia and dysphagia.
Management depends on respiratory performance, airway patency, vocal ability, and quality-of-life priorities. The
authors review the presentation, management and outcome in patients diagnosed with BVFI. The utility and efficacy
of the Empey index (EI) and the Expiratory Disproportion Index (EDI) are evaluated as an objective monitoring tools
for BVFI patients.
Methods: A 13-year retrospective review was performed of BVFI patients at St. Michaels Hospital, University of
Toronto, a tertiary referral centre for laryngology.
Results: Forty-eight patients were included; 46 presented with airway obstruction symptoms. Tracheotomy was
required for airway management in 40 % of patients throughout the course of their treatment, which was reduced
to 19 % at the end of the study period. Twenty-one patients underwent endoscopic arytenoidectomy/cordotomy.
Non-operative management included continuous positive airway pressure devices. Pulmonary function testing was
carried out in 29 patients. Only a portion of the BVFI patients met the defined upper airway obstruction criteria
(45 % EI and 52 % EDI). Seven patients had complete pre- and post-operative PFTs for comparison and all seven
had ratios that significantly improved post-operatively which correlated clinically.
Conclusion: The EI and EDI have limited use in evaluating patients with who have variable upper airway
obstruction, but may be helpful in monitoring within subject airway function changes.
Keywords: Bilateral vocal fold immobility, Bilateral vocal cord immobility, Glottis stenosis, Cordotomy,
Arytenoidectomy, Empey, Expiratory disproportion index

Background
Bilateral vocal fold immobility (BVFI) is a rare diagnosis that can be due to paralysis or fixation of the vocal
folds, and frequently associated with significant morbidity and disability. Depending on the underlying etiology, vocal fold position and compensatory behaviour,
varying degrees of dyspnea, dysphonia and dysphagia
occur [13].
Determining the need for surgery, as well as assessing
outcomes can be difficult due to the variability in etiology, symptoms and limited BVFI patient population.
* Correspondence: andersonj@smh.ca
2
St. Michaels Hospital, Department of Otolaryngology Head and Neck
Surgery, University of Toronto, 30 Bond St. 8C-129, ON M5B 1 W8 Toronto,
Canada
Full list of author information is available at the end of the article

Investigations available to assess the airway function include imaging, physical examination with endoscopy,
pulmonary function testing (PFT), sleep studies and validated quality of life questionnaires. Parameter ratios of
individual PFT values have been proposed as a potential
objective measure of upper airway function. One such
measure is the Empey Index (EI), which was described
in 1972 as a marker of upper airway obstruction by
Duncan Empey [46]. The index is the ratio of forced
expiratory volume in 1 s (FEV1) in milliliters to the peak
expiratory flow rate (PEFR) in litres per minute. The respiratory physiology is described elsewhere [46] but
can be summarized as follows:

2015 Brake and Anderson. This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any
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Brake and Anderson Journal of Otolaryngology - Head and Neck Surgery (2015) 44:27

Page 2 of 7

The ratio of FEV1 is predominantly determined by the

properties of the small intrathoracic airways and less
affected by upper airway stenosis than PEFR. In the
setting of upper airway stenosis, the ratio increases.

decannulation varied between number of cormorbities. In

all cases p < 0.05 was considered statistically significant.
Ethics approval was obtained from the St. Michaels
Hospital Research Ethics in Toronto, Canada.

In normal subjects and in patients with lung diseases

(asthma, chronic bronchitis and others) the EI ratio was
found to be less than 10 (ml/l/min). In comparison,
Empey discovered that patients with known upper airway obstruction, including those with bilateral vocal
fold fixation, all had values greater than 10 and a mean
of 14 [4].
When Nouraei et al. re-evaluated this ratio in 2013,
they proposed a modified ratio calculation of FEV1/
PEFR 100, termed the expiratory disproportion index
(EDI), using the SI units of FEV1 (L) and PEFR (L/s)
[6]. In studying the utility of the EDI, they found that
benign upper airway stenosis subjects had a mean of
76 17 s. Their study also found that the degree of
stenosis correlated with a higher EDI value. For practicality, multiplying EI ratio by six will allow conversion
to EDI units.
It is not clear whether these ratios can be useful in the
BVFI population, which includes a large proportion of
bilateral vocal fold paralysis patients. In this report, the
authors review the presentation, management and outcome in patients diagnosed with BVFI at a laryngology
clinic in a tertiary referral academic centre. Within this
group, the utility and efficacy of the EI and EDI are evaluated as an objective monitoring tool for BVFI patients.

Results
A total of 48 patients with bilateral vocal fold immobility
were identified from the institutional laryngology database. The mean age of presentation was 52 years, with
ages ranging from 15 83 years. Thirty-five (73 %) of
the patients were female. Thirty-three of the patients
(69 %) were diagnosed with bilateral vocal fold paralysis,
twelve (25 %) with joint fixation, and one was documented as a combination. Two patients were unable to
be categorized given the information available. Seven patients (17 %) were documented as smokers. Demographics
are outlined Table 1.

Material and methods

A retrospective cohort study was undertaken at an academic, tertiary-care laryngology clinic in Toronto, Canada.
All patients diagnosed with BVFI between January 1, 2001
and Dec 31, 2013 were included. Collected data included
demographics (age, gender), etiology of BVFI, past medical
history, pulmonary function testing (flow volume loop,
FEV1 and PEFR), relevant surgeries, history of tracheotomy, decannulation, and post-operative complications.
The hospital electronic medical record system was used to
review transcriptions, clinic notes, pathology reports, operative notes and pulmonary function results to collect
the data.
The data was analyzed using GraphPad Prism version
6.02. Descriptive statistics were calculated for demographics, EI, and EDIs ratios. The Wilcoxon Matched
Pairs Signed Rank Test was used to compare the paired
pre- and post- operative EIs and EDIs. Unpaired parametric t-tests were used to compare the EI/EDI ratios
between mean ages patients that underwent airway surgery, specifically a cordotomy/artenoidectomy, versus the
group that did not. Chi-squared testing was used to
determine if the rates of cordotomies, tracheostomy or

Presentation

The primary complaint for the majority of patients (75 %)

presenting to the clinic was that of dyspnea such as stridor, exercise intolerance, and airway obstruction when supine. Vocal complaints were the presenting complaint in 6
patients (12.5 %), followed by two with dysphagia or aspiration (4 %). Two patients (4 %) were seen on the recommendation of the referring doctor but reported to be
without symptomatic complaints otherwise.
Etiology

The etiology of BVFI in the study population, in decreasing order of incidence, included thyroid disease or
associated surgery, intubation-related injury, congenital,
Table 1 Patient demographics bilateral vocal fold immobility
(n = 48)
Demographics (n = 48)

n (%)

Gender
Male

13 (27 %)

Female

35 (73 %)

Documented Smokers

7 (17 %)

Diagnosis
Bilateral Vocal Fold Paralysis

33 (68 %)

Joint Fixation

12 (25 %)

Combination

1 (2 %)

Unknown

2 (4 %)

Presentation
Airway Obstruction

36 (75 %)

Dysphonia

6 (13 %)

Dysphagia/Aspiration

2 (4 %)

Other

2 (4 %)

Unknown

2 (4 %)

Brake and Anderson Journal of Otolaryngology - Head and Neck Surgery (2015) 44:27

central neurological disorders, autoimmune disease, and

surgery or cancer of cardiothoracic origin (Fig. 1).
Of the sixteen patients who suffered from bilateral
vocal fold paralysis secondary to thyroid surgery, it was
noted that 44 % (7) had their surgery outside of Canada
and the pathology could not be determined.
A head and neck cancer diagnosis was present in
eleven (23 %) patients. Four of these patients (36 %) had
BVFI secondary to direct malignant invasion of the nerve
or larynx. The other seven (64 %) developed BVFI from
cancer treatment interventions: three with post-radiation
polyneuropathy and four from injury or intentional transection during surgery for their disease.
Tracheotomy

Nineteen BVFI patients (40 %) required a tracheotomy

for airway management at some point in their management. Nine patients with tracheotomy opted to undergo
further surgical treatment with the intent to decannulate. To date, eight of these have been decannulated at
the time of manuscript preparation.
Three patients were decannulated without surgical
intervention. Overall, 17 % (8) of the 48 BVFI patients
continued to require a tracheotomy for airway control
(see Fig. 2 for full details). There was no statistical significance between the tracheostomy-dependent groups,
the groups who were decannulated or the groups that
did not require tracheostomies in terms of ages or
comorbidities.
Surgical intervention

Of the 46 patients who complained of airway obstruction, twenty one patients (44 %) underwent a unilateral
cordotomy and arytenoidectomy in order to improve the
upper airway. The remaining 25 patients either had mild
symptoms or medical comorbidities that prohibited a
cordotomy/arytenoidectomy.
Revisions were required in seven (33 %), including five
patients with persistent airway symptoms and two due
to granuloma formation. Of the patients requiring

Fig. 1 Etiologies of BVFI in the study population

Page 3 of 7

revisions, four (44 %) of the seven had BVFI secondary

to fixation: two cases of post-glottic stenosis, one case of
a Teflon granuloma, and a fourth case secondary to
SLE-related joint fixation.
Two patients required multiple revisions (see the flow
chart in Fig. 3 for full details). In one instance the patient
had notable weight gain and recurrence of Reinkes edema
in the setting of paralysis attributed to Charcot-MarieTooth disease. This individual required a contralateral
cordotomy/arytenoidectomy, followed by an external approach vocal cord lateralization via laryngofissure. After
the final procedure, the patient was able to achieve decannulation. The second patient had the aforementioned
Teflon granuloma and associated sequelae.
There was no significance between cordotomy and
non-cordtomy groups in terms of ages or comorbidities;
there was also no significance for these same variables
when comparing the revision cordotomy groups to the
single-surgery patients.
Two patients underwent medialization thyroplasty for
lateralized vocal folds in order to improve vocal function
and reduce aspiration. In both of these cases, the etiology of their BVFI was congenital resulting in widely
patent glottis and poor voice.
Empey ratio

A total of 81 PFTs had been completed on 60 % (29) of

the patient population. The surgical group (n = 21) had
49 PFTs done in total, with this group referring specifically to patients having undergone a cordotomy/arytenoidectomy and/or revision. In the non-surgical group (n =
25), 32 PFT studies were done as part of their evaluation.
Only twelve (41 %) of the 29 patients who underwent
full PFT studies met the defined EI criteria for upper airway obstruction. Fifteen patients (52 %) had EDI values
which fell within the mean range of 76 17 as described
by Nouraei et al. [4].
The EI and EDI were separated into surgical and nonsurgical groups for comparision. Within the surgery
group, comparision was also completed between subgroups: last pre-operative value, first post-operative value,
all pre-operative values and all post-operative values. It
should be noted that some patients only had pre-operative
values while some others only had post-operative values.
There was no significance found between the mean EI
and EDI ratios in the non-surgical and surgical groups,
nor between any of the subcategories.
Seven patients had complete PFT data allowing for comparison from pre to post cordotomy/arytenoidectomy.
The Wilcoxon Matched-Pairs Signed Rank Test (WSRT)
was completed on the Empey ratios and EDI for this
subgroup which showed a significant increase postsurgery (p = 0.0156), which also correlated with clinical
airway improvement. One patient was initially found to

Brake and Anderson Journal of Otolaryngology - Head and Neck Surgery (2015) 44:27

Page 4 of 7

Fig. 2 Patients requiring a tracheostomy

have a post-operative granuloma, worsening dyspnea and

an elevated EI (10.53) and EDI (63.17). A PFT was repeated following revision surgery and the final value was
used as the post-operative value for comparision.
Nineteen patients did not have records of PFTs in
their charts; two had medical reasons for not pursuing
further surgical treatment (both had long term tracheotomy) and three others had mild symptoms that did not
warrant intervention. Other patients could not complete
the PFT tasks due to airway limitations (with a corked
tracheotomy tube). It is unclear how many PFTs were
performed at outside institutions and were not added to
our institutional electronic medical record.
Other management

The majority of patients (56 %) underwent laryngeal

computer tomography. Ten patients of 46 (21 %) were
recommended to use home continuous positive airway

Fig. 3 Surgical interventions

pressure (CPAP) devices secondary to the diagnosis of

obstructive sleep apnea on the basis of abnormal sleep
studies attributable to their upper airway pathology. Of
these patients, five patients were post-operative from a
cordotomy/arytenoidectomy and the remaining five patients did not undergo any surgical airway intervention.

Discussion
Airway obstruction is the most disabling symptom in patients with BVFI. In both glottic stenosis and bilateral
vocal fold paralysis, the primary goal is to provide a
stable increase in glottic airway with minimal compromise in voice quality. Airway management depends on a
variety of factors, including their degree of upper airway
obstruction, underlying respiratory function, voice demands and quality of life priorities. Long-term tracheostomy, which was the only treatment available until 1922
[79], may be an appropriate option in some patients

Brake and Anderson Journal of Otolaryngology - Head and Neck Surgery (2015) 44:27

for either quality of life preference (voice quality) or for

medical reasons. Other patients may choose to undergo
surgical procedures in order to improve glottic airway
patency, potentially at the risk of increased dysphonia
and aspiration, in order to have the tracheotomy tube
removed.
Chevalier Jackson was the first to introduce surgical
treatment in BVFI via an open approach cordectomy and
ventriculocordectomy [10]. Poor voice and swallowing
outcome prompted modifications: submusocal resection
of the true vocal cord [11], extralaryngeal arytenoidectomy
with arytenopexy to the ipsilateral strap muscles [12], ,arytenoidectomy via a thyroid alar window [13], and arytenoid abduction with lateral suture by Woodman [14].
Techniques were further improved with the introduction
of the transoral arytenoidectomy in 1948 by Thornell
[15], and the application of endoscopic carbon dioxide
laser [1618].
Dennis and Kashima popularized the use of endoscopic posterior glottic cordotomy in 1989, which remains the most common surgical option, either as a
unilateral [19] or bilateral intervention [20]. Other reports have been published with variations on these procedures including suture techniques [2123], mucosal
approaches [24] and equipment [10].
In our cohort, bilateral vocal fold immobility was most
frequently caused by bilateral recurrent nerve paralysis
after thyroid surgery, (Fig. 1). A twenty year review of
the etiology of bilateral vocal fold immobility was completed by at Cleveland Clinic in [25]. The percentages of
BVFI attributed to thyroid surgery, intubation, cardiothoracic malignancy, neurological disease and radiation were
within 3 % or less of the rates quoted in the 20-year review; our cohort also had a higher rates of idiopathic/unknown causes (19 % vs 11.4 %) as well as rheumatologic
disease (6 % vs 2.7 %).
The majority of patients (75 %) presented with complaints of dyspnea secondary to paramedian positioned
vocal folds and inadequate airway. Rarely, patients can
present with bilaterally lateralized vocal folds; in our
case two patients presented in this fashion and underwent Type I thyroplasty. Both of these patients were
found to have congenital etiologies, suggesting a high
vagal or central pathology other than the recurrent laryngeal nerve dysfunction.
Many patients in our series did not require surgery
due to mild symptoms, and were monitored clinically
via regular clinical examinations which included laryngoscopy and serial PFTs.
The decision to treat is based on the severity of symptoms, functionality and patient priorities. For some, optimal vocal quality is worth living with a tracheostomy,
but for most, decannulation of their tracheotomy, or
improvement of their airway obstruction symptoms is

Page 5 of 7

the primary goal of treatment. Of the 21 patients who

underwent a cordotomy, 2 (10 %) failed to improve and
continued to required tracheotomy, in keeping with the
literature in this population [2, 9]. No major complications occurred in the surgical treatment group.
CPAP has been shown to effectively manage sleep
apnea without surgical intervention in patients with bilateral vocal cord paralysis and tracheal stenosis [26].
Our patients who are borderline in terms of symptoms
or those who are unwilling or unfit to undergo a permanent airway modifying surgery may benefit from nocturnal CPAP. Sleep studies are often performed on these
patients, as well as those undergoing corking trials, prior
to decannulation [27].
Pulmonary function testing is currently proposed as
the one of the most useful objective evaluation of the respiratory system, although application to upper airway
obstruction has been problematic both as a diagnostic
and quantitative measure. The ratio of FEV1 and PEFR
expressed either as EI or as EDI, has been proposed as a
useful tool in identifying upper airway obstruction [4, 6].
In our cohort, surprisingly, only half of the patients
(41 % of EI/52 % of EDI) met the published criteria for
upper airway obstruction, despite the diagnosis of BVFI
and 96 % having presented with variable degrees of airway symptoms. The proposal by Nourai [4] to utilize
EDI as a diagnostic tool for upper airway obstruction
was based on PFT results in laryngotracheal stenosis patients (n = 184). However, the pathophysiology of glottis
obstruction is unique in bilateral vocal fold paralysis
wherein the inspiratory flow is more adversely affected
than the expiratory flow based on the Bernoulli effect
[28]. This rationale may explain why our BVFI cohort,
consisting of predominantly bilateral vocal fold paralysis,
were found to have a much lower mean ratio of EDI
(52) than was reported by Nourai in fixed obstruction
patients (76). Since bilateral vocal fold paralysis is predominantly an inspiratory obstruction, It may be more
appropriate to quantified bilateral vocal fold paralysis
using a ratio containing an inspiratory parameter, such
as peak inspiratory flow rate (PIFR).
Regardless, the subgroup of seven patients who underwent a cordotomy/arytenoidectomy and who also had
complete pre- and post- PFT data, did show a statistically
significant increase in EDI/EI postoperatively, which also
correlated with clinical airway improvement. Although it
is difficult to draw a conclusion regarding the utility of this
ration based the small sample size, these findings do suggest these proposed ratios still may have some utility in
objectively monitoring patients airway status.
In bilateral vocal fold paralysis, emerging research has
shown that in a highly selected patients, re-innervation
of the recurrent laryngeal nerve using a phrenic nerve
rootlet maybe be effective in providing active abduction

Brake and Anderson Journal of Otolaryngology - Head and Neck Surgery (2015) 44:27

[29]. There is also some evidence that transecting the

RLN branch between the PCA and interarytenoid may
prevent aberrant reinnervation and help avoid synkinesis; other have taken the approach of selectively
reinnervating the adductors and the PCA muscles separately, with goals of isolated abduction during respiration
while maintaining good adduction for voice production
[28]. Reinnervation techniques of the RLN are still primarily in the research stage, but there are positive preliminary outcomes suggesting promise for bilateral vocal
cord paralysis patients in the future, particularly in
younger BVFI patients.

Conclusion
Bilateral vocal fold immobility is a challenging condition
to manage due to the significant morbidity associated
with the condition. Adequate airway management using
endoscopic cordotomies/arytenoidectomy can achieve
symptom improvement and decannulation for the majority of patients. CPAP ventilation can be a useful adjunct for those patients who continue to experience
upper airway obstruction while sleeping.
Pulmonary function testing has much potential for the
utility in the monitoring of these patients but ideal parameters in the setting of upper airway obstruction is
still unclear. In our cohort of BVFI patients, EI/EDI ratios were not overly reliable in identifying bilateral vocal
cord immobility, unlike in previously published reports.
This different could be due to anatomic differences of
BVFI versus the previous studies, which were based on
subglottic stenosis a fixed obstruction. Additional prospective data collection on this patient population, including evaluation of parameter ratios that include PFT
inspiratory flow values may help us to further understand the utility of pulmonary function testing in objectively monitoring patients with obstructive symptoms
secondary to bilateral vocal cord immobility.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
MB participated in the study design, reviewed the charts, collected the data,
participated with the statistical analysis and drafted the manuscript. JA
conceived of the study and helped to draft the manuscript. Both authors
read, edited and approved the final manuscript.
Acknowledgements
The authors would like to acknowledge Carmen McKnight for her assistance
in completing the ethics proposal, acquisition of data and data analysis.
Thank you to Michelle Kwok for her help with the literature review.
Author details
1
Department of Otolaryngology Head and Neck Surgery, University of
Toronto, Ontario, Canada. 2St. Michaels Hospital, Department of
Otolaryngology Head and Neck Surgery, University of Toronto, 30 Bond St.
8C-129, ON M5B 1 W8 Toronto, Canada.

Page 6 of 7

Received: 18 January 2015 Accepted: 16 June 2015

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