The Laryngoscope

Lippincott Williams & Wilkins

© 2007 The American Laryngological,
Rhinological and Otological Society, Inc.

Vocal Fold Immobility: A Longitudinal

Analysis of Etiology Over 20 Years
Laura H. Swibel Rosenthal, MD; Michael S. Benninger, MD; Robert H. Deeb, MD

INTRODUCTION
Objectives: To determine the current etiology of
Vocal fold immobility is a broad term used to describe
vocal fold immobility, identify changing trends over the
last 20 years, and compare results to historical reports. vocal folds that are restricted secondary to mechanical
Study Design: The present study is a retrospective fixation or neuropathy. Mechanical fixation may result
analysis of all patients seen within a tertiary care insti- from an arytenoid dislocation, edema or inflammation of
tution between 1996 and 2005 with vocal fold immobility. the glottis, or neoplastic invasion. Neurogenic immobility
The results were combined with a previous study of pa- may occur with lesions in the motor cortex or compromise
tients within the same institution from 1985 through of the recurrent laryngeal nerve at any point along its
1995. Results were compared to the literature. course from the jugular foramen to the carotid sheath,
Methods: The medical records of all patients as- mediastinum, and either around the subclavian artery on
signed a primary or additional diagnostic code for vocal the right or the aortic arch on the left, to the tracheoesoph-
cord paralysis were obtained from the electronic
ageal groove. Vocal fold movement may be partially lim-
database.
Results: Eight hundred twenty-seven patients were ited, described as hypomobility, or completely fixed or
available for analysis (435 from the most recent cohort), immobile. Vocal fold immobility may be unilateral or bi-
which is substantially larger than any reported series to lateral. The distinction between hypomobile or immobile
date. Vocal fold immobility was most commonly associ- and unilateral or bilateral is important in workup and
ated with a surgical procedure (37%). Nonthyroid surger- management because of the implications that these fac-
ies (66%), such as anterior cervical approaches to the tors have on the potential etiology and prognosis. Unilat-
spine and carotid endarterectomies, have surpassed thy- eral immobility may present as dysphonia or dysphagia,
roid surgery (33%) as the most common iatrogenic causes. or be asymptomatic. The mobile fold may compensate for
These data represent a change from historical figures in contralateral dysfunction. Bilateral immobility may
which extralaryngeal malignancies were considered the
present as obstruction often requiring intubation and tra-
major cause of unilateral immobility. Thyroidectomy con-
tinues to cause the majority (80%) of iatrogenic bilateral cheotomy. Many patients with both unilateral and bilat-
vocal fold immobility and 30% of all bilateral immobility. eral immobility may have spontaneous resolution, de-
Conclusions: This 20-year longitudinal assessment pending on the etiology. However, neoplastic invasion and
revealed that the etiology of unilateral vocal fold immo- iatrogenic division of the recurrent laryngeal nerve result
bility has changed such that there has been a shift from in permanent immobility. Inflammation, infection, or iat-
extralaryngeal malignancies to nonthyroid surgical pro- rogenic stretching of the recurrent laryngeal nerve may
cedures as the major cause. Thyroid surgery remains the cause only temporary immobility. If there is no recovery,
most common cause of bilateral vocal fold immobility. patients with unilateral immobility may benefit from a
Key Words: Vocal fold paresis, vocal fold paralysis, medialization procedure, temporary or permanent. Select
hoarseness, unilateral, bilateral.
patients with bilateral immobility may benefit from ary-
Laryngoscope, 117:1864 –1870, 2007
tenoidectomy, partial cordectomy, or lateralization. The
etiology of unilateral and bilateral immobility, therefore,
has a profound influence on workup, timing, and method
From the Department of Otolaryngology–Head and Neck Surgery, of management.1
Henry Ford Medical Group, Detroit, Michigan. Previous studies of the etiology of unilateral vocal
Editor’s Note: This Manuscript was accepted for publication May 8, fold immobility have suggested multiple etiologies. Intu-
2007. bation,2 lung cancer,3 idiopathic,4 and nonthyroid surger-
Presented at the Triological Society Combined Sections Meeting, ies5 have all been reported as the single most common
Marco Island, Florida, U.S.A., February 16, 2007.
Send correspondence to Laura H. Swibel Rosenthal, MD, Depart-
cause. Other common causes reported include thyroid sur-
ment of Otolaryngology – Head and Neck Surgery/K8, Henry Ford Hospital, gery, non-lung malignancies, and central nervous system
2799 W. Grand Boulevard, Detroit, MI 48202; E-mail: lrosenthal@alumni. disease. Surgical iatrogenic injury has historically been
upenn.edu
the most common cause of bilateral immobility.3,4 As the
DOI: 10.1097/MLG.0b013e3180de4d49 differential diagnosis is extensive, the workup may be

Laryngoscope 117: October 2007 Rosenthal et al.: Vocal Fold Immobility Longitudinal Analysis
1864
extensive as well.1 A previous retrospective review of the
etiology of vocal fold immobility of 397 cases from the
Henry Ford Health System from 1985 to 1995 showed
growing percentages of extralaryngeal malignancies and
surgery-related injuries.6 In this study, cases of vocal fold
immobility from within the same institution over the next
10 years, from 1996 through 2005, are reviewed. The
study allows evaluation of longitudinal trends within a
single institution over the last 20 years and is compared to
studies performed in many institutions over the last 50
years.

MATERIALS AND METHODS

The medical records of all patients assigned a primary,
secondary, or tertiary diagnostic code for vocal fold paralysis
(ICD-9 478.3) within the Henry Ford Health System from 1996
through 2005 were obtained from the electronic database. This
diagnostic code captures all patients with vocal fold hypomobility
and immobility. Each patient chart was retrospectively reviewed,
with institutional review board approval, to determine the follow-
ing: gender; age at diagnosis; side of vocal fold immobility;
method of diagnosis of vocal fold immobility; additional studies
for work-up, including chest radiograph (CXR), computed tomog-
raphy (CT), magnetic resonance imaging (MRI), barium swallow, Fig. 1. Etiology of unilateral vocal fold immobility, 1996 to 2005.
and electromyogram (EMG); histopathology; and the etiology of
the immobility. All cases of vocal fold immobility were diagnosed
using indirect laryngoscopy, flexible fiberoptic laryngoscopy, or
video stroboscopy. The etiology, including whether it was idio- lowed by idiopathic, 64 (17.6%); and non-upper respiratory
pathic, was recorded if adequately documented by the physician malignancies, 48 (13.5%). Lung malignancies, excluding
or the result of directed studies. Records were excluded for inad- metastatic lung disease to mediastinal or paratracheal
equate documentation of vocal fold immobility or its etiology; lymph nodes, were the most common malignant causes,
initial presentation prior to 1996, because the record would accounting for 24 cases (6.6%). There were many other
have been included in the prior study; a child less than 14
rare causes of unilateral vocal fold immobility. Rare tu-
years of age; and a primary malignancy of the upper respira-
tory tract, such as a squamous cell carcinoma of the true vocal
mors responsible included two esophageal cancers, acute
fold. Microsoft Excel Pivot Tables (Microsoft Corp, Redmond, myelogenous leukemia, glossopharyngeal and vagus nerve
WA) were used to tabulate the results. The Jonckheere- palsies from a cervical spine mass at levels C1 and C2, and
Terpstra exact test was used to evaluate trends in proportions four benign tumors of the vagus nerve. One patient had an
across years. unnamed neuropathy documented as the etiology. An-
other had an undetermined neuropathy and was later
RESULTS found to have a brain stem lymphoma. In one case it was
A diagnostic code of vocal fold immobility was assigned unknown if neck trauma or the subsequent neck explora-
to 808 patients. Of those, 373 patients were excluded, 26 for tion caused vocal fold immobility.
prior presentation within the institution, 18 for age less than Nonthyroid surgeries (111 [30.6% of all causes of
14 years old, 26 for an upper respiratory tract malignancy, immobility]) caused twice as many cases of unilateral
268 for normal vocal fold mobility, 30 for inadequate infor- vocal fold immobility as thyroid surgeries (57 [15.7%]).
mation available for analysis, and 5 for inadequate docu- Thyroid surgeries (33% of all surgical causes) include thy-
mentation of etiology. Many patients with inadequate doc- roidectomy (26%), parathyroidectomy (6%), and both thy-
umentation presented to the emergency room or the office, roidectomy and parathyroidectomy performed during the
but had no follow-up to confirm the etiology. A total of 435 same surgery (1%). The surgical procedures most likely to
patients were available for analysis of the etiology of vocal cause unilateral vocal fold immobility are shown in Figure
fold immobility. 2. The most common nonthyroid surgery to cause vocal
Of the 435 patients, 363 (83%) were unilateral and 72 fold immobility was anterior cervical spine corpectomy
(17%) were bilateral. The average age was 60 years, rang- and fusion (15%). The next most common surgical cause of
ing from 14 to 93. There were 256 female patients (61%) unilateral vocal fold immobility was carotid endarterec-
and 179 male patients (39%). For patients of unilateral tomy (11%). Other iatrogenic causes include surgery of the
immobility, 58% of these were female and 42% were male. lungs, mediastinum, heart, heart valves, aorta, and skull
There were 142 cases of the right vocal fold (39%) and 221 base; craniotomies for tumor or aneurysm; surgery of the
were of the left vocal fold (61%). For patients of bilateral esophagus; and other procedures of the neck. There were
immobility, 61% were female and 39% were male. cases of unilateral vocal fold immobility after a cricopha-
The etiology of unilateral vocal fold immobility for the ryngeal myotomy, botox injection for cricopharyngeal
most recent cohort is shown in Figure 1. The most common spasm, esophageal dilation, and excision of benign vocal
causes were surgical iatrogenic injury, 168 (46.3%); fol- fold lesions.

Laryngoscope 117: October 2007 Rosenthal et al.: Vocal Fold Immobility Longitudinal Analysis
1865
Fig. 2. Surgical causes of unilateral vocal fold immobility, 1996 to Fig. 4. Surgical causes of bilateral vocal fold immobility, 1996 to
2005. 2005.

pathic (6 [8.3%]) and neuropathy (5 [6.9%]), such as

The etiology of bilateral vocal fold immobility for the Myasthenia Gravis or Kennedy’s syndrome.
most recent cohort is shown in Figure 3. Similar to uni- The prior study from 1985 to 1995 within the same
lateral immobility, surgery was the most common cause of institution had a total of 280 patients (70%) with unilat-
immobility (55.6% [40 of 72 patients]). For surgical etiol- eral immobility and 117 (30%) with bilateral. The total
ogies of bilateral immobility, however, thyroid surgeries number of patients included in the longitudinal study is
(thyroid, parathyroid, or both) resulted in the majority of 827; 643 (78%) with unilateral immobility and 184 (22%)
cases (89%). The surgical causes of bilateral immobility with bilateral immobility. The combined data for the eti-
in the most recent cohort are shown in Figure 4. Malig- ology of unilateral immobility is presented in Table I.
nancy caused bilateral immobility in seven patients Surgery was the most common cause (36.5%). Thyroid
(9.7%). There were cases of pulmonary metastases to surgery accounted for one third of surgical causes (12.4%
mediastinal nodes, one case of an esophageal malig-
nancy that eroded through the trachea, one case of
cervical cancer metastasizing to the paratracheal nodes,
TABLE I.
and one case of lymphoma in the mediastinum. Intuba- Etiology of Unilateral Vocal Fold Immobility, 1985 to 2005.
tion also caused immobility in seven patients (9.7%).
After surgery, malignancy, and intubation, the next 1985–1995 1996–2005 1985–2005

most common causes of bilateral immobility are idio- n % n % n %

Surgery 67 23.9 168 46.3 235 36.5

Thyroid 23 8.2 57 15.7 80 12.4
Nonthyroid 44 15.7 111 30.6 155 24.1
Malignancy 69 24.6 49 13.5 118 18.4
Lung 55 19.6 24 6.6 79 12.3
Metastatic 4 1.4 12 3.3 16 2.5
Thyroid 3 1.1 8 2.2 11 1.7
Esophageal 7 2.5 2 0.6 9 1.4
Other 0 0 3 0.8 3 0.5
Idiopathic 55 19.6 64 17.6 119 18.5
Trauma 31 11.1 8 2.2 39 6.1
Intubation 21 7.5 16 4.4 37 5.8
CNS 22 7.9 11 3.0 33 5.1
Infectious 13 3.6 13 2.0
Inflammation 7 1.9 7 1.1
Radiation 3 0.8 3 0.5
Stenosis 3 0.8 3 0.5
Aortic aneurysm 2 0.6 2 0.3
Other 19 5.2 19 3.0
Total 280 363 643
Fig. 3. Etiology of bilateral vocal fold immobility, 1996 to 2005. CNS ⫽ central nervous system.

Laryngoscope 117: October 2007 Rosenthal et al.: Vocal Fold Immobility Longitudinal Analysis
1866
 TABLE II.
Comparing the current study to the study from the
Etiology of Bilateral Vocal Fold Immobility. previous 10 years within the same institution, there are
significant differences. For unilateral vocal fold immobil-
1985–1995 1995–2005 1985–2005
ity, the proportion of cases caused by surgical injury dou-
n % n % n % bled from 23.9% to 46.4% (Table I). Both thyroid and
nonthyroid surgeries doubled. There was an increase in
Surgery 30 25.7 40 55.6 70 37.0
the total number of thyroid surgeries performed over that
Thyroid 21 18 35 48.6 56 26.9
time, which may account for this increase. The proportion
Nonthyroid 9 7.7 5 6.9 14 7.4 of malignant etiologies decreased 50% (from 24.7% to
Malignancy 20 17 7 9.7 27 14.3 13.2%), despite an increase in the number of metastatic
Lung 6 5.1 3 4.2 9 4.8 and thyroid malignancies (1.4% to 3.3% and 1.1% to 1.2%,
Metastatic 4 3.4 2 2.8 6 3.2 respectively). The number of idiopathic cases has re-
Thyroid 0.0 0 0.0 mained stable, and now equals malignancy as the sec-
Esophageal 10 8.5 1 1.4 11 5.8 ond most common cause of unilateral vocal fold immo-
Other 1 1.4 1 0.5 bility. The number of traumatic injuries is significantly
Intubation 18 25.4 7 9.7 25 13.2 less, as is the number of intubation-related causes. This
may be attributed to changes in management of intu-
Idiopathic 15 12.8 6 8.3 21 11.1
bated patients within the institution, in particular,
CNS/Neuropathy 15 12.8 5 6.9 20 10.6
well-established hospital guidelines regarding length of
Trauma 13 11.1 1 1.4 14 7.4
intubation and endotracheal and tracheostomy care.
RA/Inflammation 4 4.3 1 1.4 5 2.6 These trends in increasing immobility from thyroid sur-
Radiation 2 1.7 1 1.4 3 1.6 gery and nonthyroid surgery and decreasing immobility
Stenosis 2 2.8 2 1.1 from malignancy are consistent with the literature, as
Infectious 1 1.4 1 0.5 shown in Table III.
Other 1 1.4 1 0.5 Table III shows the changing etiology of unilateral
Total 117 72 189 vocal fold immobility over the last century. There is value
in estimating whether a trend exists in these data. How-
CNS ⫽ central nervous system; RA ⫽ rheumatoid arthritis.
ever, to aid a relatively subjective evaluation of the data,
the Jonckheere-Terpstra exact test10 was used as an ad-
ditional tool to determine whether there was a statisti-
of all unilateral vocal fold immobility). Nonthyroid surger- cally significant increasing or decreasing trend based on
ies were responsible for two thirds of surgical causes the values reported in order of their year of publication.
(24.1% of the total). Idiopathic and non-upper respiratory There is no great statistical test to evaluate trends. In
malignancies were the second and third most common addition, this test may be limited as the trend is deter-
causes (18.4% and 18.5%, respectively). Two thirds of ma- mined by publication date regardless of how many years
lignancies were of the lung (12.3% of all cases of unilateral passed between publication dates or the time period over
immobility). Trauma (6.1%), intubation (5.8%), central which vocal fold immobility data were gathered. This in-
nervous system disease (5.1%), infection (2.0%), inflam- formation was not published in all reports.
mation (1.1%), radiation therapy (0.5%), stenosis (0.5%), There is a statistically significant decrease in malig-
and aortic aneurysm (0.3%) were less common causes. nant causes of unilateral vocal fold immobility in the last
The combined longitudinal data for the etiology of 10 years, from 34.8% lung and nonlung malignant etiolo-
bilateral immobility over the last 20 years are presented gies published in 1970 by Parnell and Brandenburg,2 to
in Table II. As with unilateral immobility, surgery (37.0%) 13.5% in the current study. Malignancy may become a less
far exceeds malignancy (14.3%) as the most common cause significant cause of vocal fold immobility as lung cancers
of bilateral immobility. Eighty percent of the surgeries are detected and treated earlier. There is a statistically
were of the thyroid, parathyroid, or both. Most malignan- significant growing trend in surgery-related injuries to
cies were either lung (4.8%), esophageal (5.8%), or meta- the recurrent laryngeal nerve. The proportion of nonthy-
static (3.2%). Less common causes of bilateral immobility roid surgeries causing vocal fold immobility has increased,
include intubation (13.2%), idiopathic (11.1%), central from 19% of surgeries (4.6% nonthyroid of 24.4% total
nervous system or peripheral nervous system disease surgical cases) published in 1970 by Parnell and Branden-
(10.6%), and trauma (7.4%). burg,2 to 66% (30.6% nonthyroid of 46.3% total surgical
cases) in the current study. The increase in proportion of
DISCUSSION surgical injuries may be secondary to an increase in the
This study yields both expected and unexpected numbers of surgeries, including thyroidectomy, anterior
trends in the etiology of vocal fold immobility, both within approaches to the cervical spine, carotid endarterecto-
this institution and compared to prior literature. The com- mies, or procedures elsewhere along the course of the
bined data from 1985 to 2005 in this report comprise the recurrent laryngeal nerve. Nearly all other causes of uni-
largest study of unilateral vocal fold immobility report- lateral vocal fold immobility show declining proportions,
ed.3,7,8 Although other studies have spanned 20 years,9 including central nervous system causes, aortic or cardiac,
this is the only reported longitudinal study within one and traumatic. These also may be relative changes as
institution. surgical cases have increased.

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1867
 TABLE III.
Changing Etiology of Unilateral Vocal Fold Immobility.
Henry Ford Hospital
Parnell 1970, Maisel 1974, Titche 1976, Terris 1992, Benninger 1985–1995, 1996–2005, Trend
n ⫽ 86 (%) n ⫽ 127 (%) n ⫽ 134 (%) n ⫽ 84 (%) n ⫽ 280 (%) n ⫽ 363 (%) P Value

Thyroid surgery 19.8 8.7 3.7 8.3 8.2 15.7 Increasing* .0496
Nonthyroid surgery 4.6 7.0 6.7 26.2 15.7 30.6 Increasing* ⬍.0001
Malignancy of the Lung 17.4 8.7 22.4 16.7 19.7 6.6 Decreasing* .0005
Nonlung malignancy 17.4 16.5 15.7 23.8 5.0 6.9 Decreasing* .0009
Intubation - 3.1 3.7 7.0 7.5 4.4 Increasing .22
CNS 5.8 7.9 15.7 2.4 7.9 2.8 Decreasing* .0002
Aortic/cardiac 3.5 6.3 1.5 - 4.3 0.6 Decreasing* .0004
Idiopathic 11.6 26.8 2.2 10.7 19.6 17.6 Increasing .53
Trauma 2.3 10.2 3.0 1.2 11.1 2.2 Decreasing* .01
Other 17.4 4.7 25.4 3.6 1.1 12.6 Decreasing .53
*Statistically significant, P ⬍ .05.
CNS ⫽ central nervous system.

Within the institution, similar changes were seen in heart surgeries. The decline in total surgical causes of
bilateral vocal fold immobility. Surgical causes of bilateral bilateral immobility in the literature may be a result of
vocal fold immobility have doubled, and malignant causes decreasing proportions of immobility from thyroidec-
have declined. As with unilateral immobility, this may tomy. However, this study is consistent with early stud-
have resulted from increasing numbers of thyroidec- ies in which thyroidectomy accounted for a large major-
tomy, bilateral carotid endarterectomy, or other surgi- ity of bilateral vocal fold immobility.3,7 Similarly,
cal procedures within the institution, but it is a depar- malignancy caused less bilateral vocal fold immobility
ture from statistically significant trends in the than expected by its increasing trend, which is possibly
literature, as shown in Table IV. Table IV demonstrates a consequence of the high number of iatrogenic injuries
the changing trends in the etiology of bilateral vocal fold within this institution.
immobility. Iatrogenic injury from all surgical proce- Of the 435 patients in the most recent cohort, there
dures is decreasing. However, nonthyroid surgeries, were many more cases of unilateral than bilateral immo-
which are much less common causes, are increasingly bility, which is expected because injury to one nerve is
responsible for bilateral immobility,3,7–9 from 1.9% of more likely than to both. In the current cohort, the left
bilateral immobility as published by Maisel and Ogura3 nerve (61%) was more commonly injured than the right
in 1974 to 6.9% in the current study. The nonthyroid (39%). This is consistent with the 1985 to 1995 study (left
surgeries causing bilateral immobility are less often accounted for 62% and right 38%) as well as prior litera-
associated with carotid endarterectomy or anterior ap- ture. This may be because the left recurrent laryngeal
proaches to the cervical spine because these are typi- nerve is longer and more vulnerable. Specifically, it trav-
cally one-sided procedures. Of the cases of documented els into the left chest and much of the difference can be
bilateral immobility from nonthyroid surgery, two cases accounted for by intrathoracic malignancy. In the most
included carotid endarterectomy, and two included recent cohort, there were 38 cases of left vocal fold

TABLE IV.
Changing Etiology of Bilateral Vocal Fold Immobility.
Henry Ford Hospital
Maisel 1974, Holinger 1976, Feehery 1982–1997, Benninger 1985–1995, 1996–2005, Trend
n ⫽ 54 (%) n ⫽ 240 (%) n ⫽ 75 (%) n ⫽ 117 (%) n ⫽ 72 (%) P Value

Surgery (thyroid and nonthyroid) 42.6 58.8 19.0 25.7 55.5 Decreasing* .0015
Thyroid surgery 40.7 57.5 11.8 18.0 48.6 Decreasing* ⬍.0001
Nonthyroid surgery 1.9 1.3 8.0 7.7 6.9 Increasing* .0015
Malignancy (lung and nonlung) 7.4 6.7 21.4 17.0 9.7 Increasing* .01
Intubation 1.8 — 9.3 15.4 9.7 Increasing .11
CNS 7.4 21.7 18.7 12.8 6.9 Decreasing .09
Idiopathic 3.7 3.3 13.3 12.8 8.3 Increasing* .002
Trauma 27.8 0.8 9.3 11.1 1.4 Decreasing .11
Other 9.3 8.8 9.3 5.1 8.4 Decreasing .45
*Statistically significant, p value ⬍.05.
CNS ⫽ central nervous system.

Laryngoscope 117: October 2007 Rosenthal et al.: Vocal Fold Immobility Longitudinal Analysis
1868
immobility secondary to malignancy and 22 (56%) were ber of thyroidectomies performed within this institution
lung malignancies. There were 10 cases of right vocal fold may be increasing, the number of high-risk patients at
immobility secondary to malignancy, two (20%) were of this tertiary care facility in a large urban area with a
the lung and four (40%) were of the thyroid. There were 26 large referral pattern may be disproportionate. Perhaps
cases of right vocal fold immobility from thyroid surgery recurrent laryngeal nerve monitoring will show im-
and 31 cases of left vocal fold immobility from thyroid proved efficacy in the future, especially for seemingly
surgery. high-risk patients, such as thyroidectomy patients with
Accuracy of this study relies on adequate workup and malignancies, large multinodular goiters, or previous
documentation. In this study, etiology was properly eval- thyroidectomy.
uated based on the patient’s history and physical exami-
nation. Many patients presented with a history of voice
CONCLUSION
complaints following surgery, and therefore no additional
A review of 827 patients with vocal fold immobility
studies were necessarily required. When immobility re-
(643 unilateral and 184 bilateral) over the last 20 years
sulted from intubation, there was adequate workup to
has shown consistency with previous reports of surgical
determine the pathophysiology of the immobility. An ac-
iatrogenic injury causing increasing proportions of unilat-
curate account of how many patients had neuropathy ver-
eral vocal fold immobility. Thyroid surgeries continue to
sus ankylosis cannot be made in this retrospective study.
cause a significant proportion of recurrent laryngeal nerve
Other patients had further diagnostic studies using imag-
injury, but nonthyroid surgeries are increasingly respon-
ing, such as a CXR, CT, MRI, or barium swallow, or EMG.
sible for such injuries. Carotid endarterectomy, anterior
These diagnostic tools are also valuable in development of
approaches to the cervical spine, and heart or great vessel
a treatment plan. Frequently, patients presented to the
surgeries currently cause more iatrogenic unilateral im-
office with previous workup, including outside imaging.
mobility than thyroid surgery does. However, this study
One hundred percent of patients with a diagnosis of idio-
shows some departure from trends identified in prior stud-
pathic etiology had additional workup, supporting ade-
ies. Extralaryngeal malignancy, thought to be a growing
quate workup for that diagnosis.
cause of unilateral immobility, is a declining cause of
Understanding the etiology of vocal fold immobility is
unilateral immobility, for both lung and nonlung malig-
an essential element of appropriate workup and manage-
nancies. Surgical injuries now surpass extralaryngeal ma-
ment. How often iatrogenic injury causes permanent as
lignancy as the most common etiology for unilateral im-
opposed to temporary disability cannot be ascertained
mobility. Bilateral immobility, which is much less
from this study. Of the 808 patients in the database with
common than unilateral immobility is, has shown a dif-
vocal fold immobility, 303 were excluded for inadequate
ferent trend. Contrary to unilateral immobility, surgery is
documentation of immobility, etiology, or other necessary
causing less bilateral immobility, although the trend is
information for analysis. The documentation is often in-
not strong and malignancy is increasingly responsible for
adequate because patients were seen in the emergency
bilateral immobility. Other common causes of vocal fold
room or office once and did not have follow-up with ade-
immobility, aside from surgery and malignancy, have re-
quate workup. Many of these patients may have iatro-
mained stable. Idiopathic etiologies remain common
genic, either surgical or intubation-related immobility, or
causes of unilateral immobility and intubation remains a
infectious etiologies, but were lost to follow-up, possibly
common cause of bilateral immobility.
because their symptoms resolved. This may be especially
Determining the mechanisms of vocal fold immobility
true of patients with unilateral vocal fold immobility. A
plays a significant role in developing an appropriate man-
prospective study would further delineate the prognosis
agement plan. Furthermore, understanding the etiology of
and appropriate management for patients with a new
vocal fold immobility within a population should allow for
onset vocal fold immobility.
decreased morbidity and prevention of immobility.
The current study allows for appreciation of where
to direct efforts to prevent neuropathy and minimize
morbidity from vocal fold immobility. Intraoperative BIBLIOGRAPHY
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