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Ext ra l a ryngea l

C a u s e s

o f

V o c a l C o rd P a ra ly s is :

C T

E va l ua t i on

H a r v e y S. Glazer1

D ix ie J . A ro n be rg

Jos ep h K . T . L ee

Stua r t

S . S a g e l

C o m p u te d to m o g ra p hy C T ) w a s u se d in 3 3 p a tie n ts to e v a lu a te p os s ib le ex tra -

la ry n g e a l c au s e s o f v o c a l co rd p a ra lys is 2 2 le ft, 1 1 r ig h t). N eo p la sm in th e lo w e r ne c k

o r u p p e r m e d ias tin u m lu n g , e so p h a gu s , th yro id , b re as t, ly m ph o m a ) w a s fo u n d to b e

th e p red o m in an t c a u se 2 7 /3 3 ) . A n e g ativ e C T e xa m in a tio n c o rre la te d w ith a ne u ro -

p a th ic e .g ., d iab e te s ) o r id io p a th ic e tio lo g y . C T p ro ve d u s e fu l in d em o n s tra tin g o r

ex c lu d in g a b n o rm alities in a rea s th a t a re d iffic u lt to e va lu a te b y p h ys ica l e xa m ina tio n

o r c o n ve n tio n a l ra d io g rap h y , p a rtic u la rly th e a o rto p u lm o na ry w in d o w . T h e no rm al

an a to m y a n d p ath o lo g ic m a ss e s in v o lv in g th e re cu rre n t la ry n g e a l n e rv e a re illu s tra te d .

V oc a l c o rd pa ra lys is is a re la tiv e ly c om m o n c lin ic a l o ccu rre nce . A ltho u gh

la ryn g ea l ca rc in om a an d la ry ng ea l trau m a are o bv iou s ca us es o f a pa ra lyze d

tru e v oc a l co rd , a va rie ty o f e x tra la ryng e a l d is ea se s ca n a ffec t th e re cu r ren t

la ryn g ea l b ra n ch o f th e va g us ne rve an d re su lt in vo ca l co rd p a ra lys is .

C o m p u te d tom og ra ph y (C T ) ca n b e va lu ab le in de m o n s tra ting la ryn g ea l a b -

n o rm a lit ie s tha t le ad to a pa ra lyz ed tru e vo ca l c o rd [1 ]. H ow e ver , th e ro le o f C T

in the e va lua tio n o f th ose pa tie n ts w h o do no t ha ve la ry ng ea l d ise as e h as no t

b ee n em ph as ize d . W e re v iew ou r ex pe rie n ce w ith C T in d ia gn o s in g e x tra la ry n -

ge a l c au se s o f vo ca l co rd p a ra ly s is .

M ate ria ls a n d M e th o d s

B etw ee n A pril 1 97 9 an d S e p te m b er 1 982 , 77 pa tien ts w ith a la ry ng os cop ic d iagn os is o f

v oca l co rd p a ra lys is had a C T sca n o f th e n e ck a n d /o r c he s t as p a rt o f th e ir e va lu a tio n . O f

th es e pa tie n ts , 3 2 ha d kno w n la ryn ge a l ca rc in om a a nd 1 2 h ad a h is to ry o f la ryn gea l trau m a

(a u to acc ide n t), t rac he a l in tub a t ion , o r th yro id s u rg e ry . T h e o th e r 33 p a t ien ts fo rm the ba s is

o f th is re po rt. F ou rte en o f th ese 33 pa tie n ts had a h is to ry o f p r io r m a lig na n t n eo p la sm a t

the tim e o f the C T exa m ina tion .

T he pa tie n ts (2 2 m en ,

1 1 w om en) w ere 25 -81 y ears o f age (ave ra ge , 53 y ea rs). A ll

co m p la ined o f h oa rse ne ss la s tin g fro m 1 w ee k to 1 y ea r (m ed ian , 1 m o n th ).

A ll pa tie n ts w ere sc an ned on a s ub -5 -se c C T sca nn er (E M I 7 07 0 , S iem e ns D R 3 , o r

S iem en s S om atom 2 ). T he reg ion sc an ned w a s d ic ta te d b y the c lin ica l h is to ry (i.e .

,

rig h t o r

le f t tru e vo ca l c o rd pa ra lys is ), ph ys ica l find ing s , a nd pre v io us ra d io log ic ex am in a tio ns .

A n a t o m y

R ece iv ed Ja nuary 1 7. 1 983 ; ac cep ted a fte r

re vis io n A pri l 1 2, 1 983 .

A ll au tho rs : M a llinckrod t Ins titu te o f R ad io l-

ogy . W ash in g ton U n ive rs ity S choo l o f M ed ic ine .

510 S . K ing sh ighw ay, S t. Lou is , M O 631 10 . A d-

d ress rep rin t reques ts to H . S . G laze r.

A JR 1 41 :5 27-53 1, S e p tem be r 19 83

0361 803X/83/ 1413 0527

A m eric an R oen tgen R ay S ocie ty

T he v oca l co rd s a re in ne rva ted b y th e rec u rre n t la ryn ge a l n e rv es . K no w le dg e

o f th e an a to m ic co u rse o f thes e ne rve s is ne ce ssa ry fo r th e ra d io lo g is t to p e r fo rm

an ad eq ua te C T e va lua tion in p a tie n ts w ith vo ca l co rd p a ra lys is (fig s . 1 an d 2 ).

E ach n erv e a cco m p a n ies th e trun k o f the va gu s ne rve as it d es cen d s in the n eck

ad jac en t to the in te rna l ca ro tid a rte rie s .

T h e rig h t re cu r ren t la ryn ge a l ne rve h as a d iffe ren t c ou rse fro m th e le ft. It

lea ve s the va gu s n erv e a t th e a n te rio r su rfa ce o f the rig h t su bc la v ia n a rte ry an d

ru ns in fe rio rly , loo p ing a rou nd the sub c la v ia n a rte ry , the n asc en ds m ed ia lly in

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A

B

D

E

F ig . 1 -S c he m a tic d ra w ing de m o ns tra t ing c ou rse o f rig h t a nd le ft rec u r-

ren t la ry ng ea l n e rves . L e tte rs A -E co rre spo nd to res pe ctiv e leve ls o f t ran s-

v e rse ana tom ic d iag ram s in f ig . 2 . T C thyro id ca rtilag e ; T h

=

th y ro id ; R S A

- righ t s ub c la v la n a rte ry ; L S A = le ft su bc la v ia n a rte ry ; C = c aro tid a rte ry ;

A A -

aortic a rch .

528

G L A Z E R E T A L . A JR :1 41 , S ep te m be r 19 8 3

pa tie n ts a ls o h ad lym p h no d e e n la rge m e n t la te ra l to th e

the tra che o es op ha g ea l g roo ve .

T he le ft re cu rre n t ne rve b ra nc he s m u ch m o re c au d ad

from the vag u s ne rve o n the a n te rio r su rface o f th e ao rtic

a rc h . It p a sse s in fe rio rly a ro u nd th e a rch th ro u gh th e ao r-

top u lm o na ry w ind o w to asc en d in the trach e oe so ph ag e a l

g roo ve . B o th re cu rren t la ryng e a l n e rv es a re in tim a te ly as -

so c ia ted w ith the thy ro id g la nd b e fo re en te ring the la ryn x

under the cricopharyngeal muscle

R e s u l ts

Le ft V o ca l C o rd P a ra lys is

N in ete en o f 2 2 c as e s o f le ft v o ca l co rd p a ra lys is w e re

se co nd a ry to m a lig na n t n eo p las m (1 4 lu ng , tw o b re as t, on e

th y ro id , o ne eso p ha gu s , an d o ne lym ph o m a) in vo lv in g th e

le ft recu rre n t la ryn g ea l n e rv e (fig s . 3 a nd 4). O n e pa tie n ts

vo ca l co rd pa ra lys is w as s eco n da ry to a n a o rtic a ne urysm

(fig . 5 ). T w o p a tien ts h ad id iop a th ic le ft true vo ca l co rd

pa ra ly s is , d o cu m e n ted b y c lin ic a l fo llo w -up .

In 1 8 o f 20 p atie n ts w ith a d o cu m e nted ex tra la ry ng e a l

cau se o f le ft true v oca l co rd p a ra lys is , C T sc an s sho w ed a

m ass 1 -7 c m in d iam ete r (ave ra ge , 3 cm ) in th e a o rto pu l-

m on a ry w in do w , p re su m a b ly inv o lv in g th e le ft re cu r ren t

la ryng e a l ne rve as it pa sse s u nd e r th e ao rtic a rch to a sce n d

b e tw ee n the trac he a a n d the e sop h ag us . O ne o f th es e

a ortic a rch a lo ng the co u rse o f the n e rve ju s t ce ph a lad to

the ao rtop u lm o na ry w in d ow (fig . 4 ). In 1 3 o f th e 1 8 c ase s in

w h ich the re w a s a m a ss in th e a o rtop u lm o na ry w ind ow th is

re g ion o f th e m e d ia s tin um a pp ea re d n orm a l o n rou tin e c he s t

ra d iog ra ph s . In the se 1 3 ca se s th e m a ss w a s 1 -3 .3 cm in

d ia m e te r (a ve ra ge , 2 .3 cm ), w h ile th o se ca ses w ith an

a bn orm a l m ed ia s tin a l c on tou r o n c he s t rad io g rap h s ha d

m a sse s 3 .8 -7 cm in d ia m e te r (a ve rag e , 4 .6 cm ). T h e o th e r

tw o p a tien ts ha d m ass es (o n e thy ro id ca rc ino m a , o ne lym -

ph om a in lym ph n od e s) in th e n e ck , b o th c lin ica lly pa lp ab le ,

in the exp e c ted p o s itio n o f the le ft re cu rren t la ryng e a l ne rve .

R igh t V o ca l C o rd P a ra lys is

E ig h t o f 1 1 c ase s o f rig h t v oca l co rd pa ra lys is w e re

,_

se co nd ary to m a lign a n t ne o p lasm (th ree lu ng , th ree e so ph -

Li

a gu s , an d tw o th y ro id lym p ho m a ) invo lv in g the recu rre n t

la ry ng ea l n e rve in th e rig h t s id e o f th e n eck o r rig h t lu ng

a p ex fig s . 6 a n d 7 ). In th re e p atie n ts n o a na to m ic c au s e o f

th e voc a l co rd pa ra lys is c ou ld b e fou n d ; tw o are p re sum ed

to resu lt from d iab e tic n e u ro pa thy a nd the o the r is p rob a b ly

i di op at hi c i n e ti ol og y

C T s can s in a ll e ig h t p a tie n ts w ith m a lign an t n e op la sm s

de m o ns tra ted a la rg e so ft t is sue m a ss in th e e xpe c te d

co u rse o f th e righ t re cu rren t n e rve . In a ll e igh t, th e m a ss

w a s e ith e r p a lpa b le on ph ys ica l ex am in a tio n o r ev id en t o n

co nv en tio na l rad io g ra p hy .

D i s c us s i on

M os t e x tra la ryng e a l ca se s o f vo ca l co rd p a ra lys is in a d u lts

a re sec on da ry to a cqu ired co nd ition s w h ich m ay in vo lve the

rec u rre n t la ryn ge a l n e rve a t an y po in t a lo n g its a na tom ic

cou rse . T he e tio log y o f su ch v oca l co rd p a ra lys is de pe n ds

on the p op u la tio n s tu d ie d . In so m e se rie s , the m os t fre q ue n t

cau se o f u n ila te ra l voc a l co rd p a ra lys is w a s tra u m a [2 -4 ].

la tro ge n ic in ju ry re su ltin g fro m th y ro id , ra d ica l ne ck , a nd

m ed ia s tin a l s u rg e ry a s w e ll as g u nsh o t w ou n ds , b ra in in ju -

rie s , a n d au tom ob ile acc id en ts ha ve a ll b e en a sso c ia ted

w ith vo ca l c o rd pa ra lys is . C T is ge n era lly n o t req u ire d in th is

g ro up , s ince th e c lin ica l h is to ry u su a lly es ta b lishe s the

etiology

M a lign an t n eo p las m h as b e en rep o rte d as th e m o s t c om -

m on c au se o f ex tra la ryn g ea l vo ca l co rd p a ra lys is [5 -7 ].

N e op la sm s o f th e thy ro id , eso p ha gu s , m e d ias tinu m , a n d

lu ng a re no t in fre qu en tly co m p lic a te d b y voc a l c o rd pa ra ly -

s is . T um ors in vo lv in g th e jug u la r fo ra m ina a lso can res u lt in

voc a l co rd p a ra lys is . T he m o s t co m m on ex tra la ry ng ea l m a -

lig na nc y ca u s in g vo ca l co rd p a ra lys is is b ro nc ho ge n ic ca r-

c in om a (1 7 o f 2 8 c ase s in ou r se rie s ). In th e se pa tie n ts it is

the le ft re cu rren t la ryn ge a l ne rve th a t is m o s t fre qu e n tly

in vo lve d (1 4 o f 1 7 c ase s ) as it co u rse s th rou gh th e a orto -

pu lm on a ry w in do w . H ow ev er, r igh t-s ide d m e d ias tina l a de -

no pa thy ex ten d ing cep h a lad to th e reg io n o f the righ t sub -

c la v ia n a rte ry c an a lso in vo lve th e rig h t rec u rren t la ryn ge a l

ne rve . In a dd itio n , pa tie n ts w ith a su p erio r s u lcu s tum or ca n

d ev e lop vo ca l co rd pa ra lys is w h e n th e tum or ex te nd s in to

th e su p rac lav icu la r s pa ce .

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A

C

D E

A B

A J R :1 41 , S e p te m b er 19 83

CT OF VOCAL CORD PARALYSIS

529

BV

F ig . 2 .- A -E ,

c on se cu t ive tran sv e rs e d ra w ings sh ow ing re la t ion o f re cu r ren t la ryng ea l ne rve s a r r ows to ad jace n t s truc tu res a t le ve ls d ep ic ted in fig . 1 .

T

= tra ch ea ; th =

thyro id ; E

= es op ha gu s; C =

ca ro tid a rte ry ; J

= jug u la r v e in ; M = s te rno c le id om as to id m us c le ; L = lu ng ; S =

s ubc lav ian a rte ry ;

I = in nom in a te v e in ; B = b rac h io ce pha lic a rte ry ; v = su per io r ven a c av a ; A A =

asc end ing aorta ; D A

= de sce nd ing aor ta ; a rrow hea d = va gu s ne rve .

F ig . 3 -79 -y ea r-o ld m a n w ith pa ra ly ze d le f t

true v oca l co rd . A , C h est ra d io g raph . Irre gu la r

c av ita ry m ass a r r ow

in le ft uppe r lobe . N o m e-

d ias tin a l a bn o rm a lity is se en . B , C T s ca n sho w s 3

c m m a ss (M ) in ao rto pu lm o na ry w ind ow fla tten ing

le ft s ide o f tra che a (T ). A A = as cen d ing a orta ; D A

=

d esc en d in g ao rta ; v

=

s up erio r ve na c ava .

S ub seq ue n t s pu tum c yto lo gy w as po s it ive fo r ep -

id er mo id c arc in om a .

In m os t s e ries , in fec tion s a nd n eu ro lo g ic d ise ase s a c -

cou n t fo r le ss tha n 1 0 o f c ase s o f un ila te ra l voc a l c o rd

p a ra lys is [2 , 4 , 5 , 7 ]. A b ou t 1 0 -30 o f c as es o f vo ca l

co rd p a ra lys is ha ve b ee n re po rte d a s id io pa th ic . M an y p a-

tien ts w ith no a pp a ren t e tio log y w ill h ave spo n ta n eo us re s -

o lu tio n o f the p a ra lys is ; p res um ab ly so m e o f th es e ca se s

a re cau se d by v ira l in fe c tio n s .

T h e m a na ge m e n t o f pa tie n ts w ith voc a l co rd p a ra lys is

re q u ires e s tab lish ing the s ite a s w e ll a s th e c au se o f th e

p a ra lys is . W h ile c lin ica l h is to ry w ill re ve a l th os e p a tien ts

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