HSC Section 6 Nov2016 Green Book

Otolaryngology–Head and Neck Surgery 151(2)

WUSM. The etiology with the largest delay between symp- tom onset and treatment was trauma at 563 months, while several etiologies had delays of only 0.5 months. Etiologies with the greatest percentage of patients presenting to an out- side otolaryngologist before a WUSM otolaryngologist included carotid surgery (18.2%), laryngeal surgery (25.0%), parathyroid surgery (16.7%), thyroid surgery (12.1%), laryn- geal cancer (20.0%), thyroid cancer (28.6%), idiopathic causes (16.9%), CVA (22.2%), and neck radiation (25.0%). Figure 2 displays histograms of time of presentation to any otolaryngologist and to a WUSM otolaryngologist within 3 years of symptom onset, as well as cumulative per- centages of patients who presented within this time window. It can be seen that 81% of patients present within 6 months, 89% within 1 year, and 93% within 2 years. In Figure 3 , the same data focus on the first 4 months after onset, during which 44% present within the first month (many during the same hospital stay during which the paralysis began), 63% within 2 months, 71% within 3 months, and 75% within 4 months. These are the patients for whom an early interven- tion strategy might be an option. The cumulative plots for all patients and for WUSM-only have similar contours because the WUSM referral group comprises 90.2% of the patients. Table 4 shows the first 4-month presentation data by etiology, excluding those groups with less than 10 patients. Etiologies with the greatest percentage of patients present- ing to the WUSM within a 4-month period included esopha- geal cancer (90.9% present within 4 months), skull base surgery (88.9%), esophageal surgery (86.5%), intubation (86.2%), lung surgery (84.9%), and lung cancer (82.2%). Etiologies with the lowest percentage of patients presenting to the WUSM within a 4-month period included idiopathic causes (54.8%), CVA (55.6%), thyroid cancer (57.1%), and carotid surgery (59.1%). In patients who had UVFP caused by thyroid surgery, 66.4% presented to the WUSM within 4 months, and in patients with parathyroid surgery, 72.2% presented to the WUSM within 4 months. In this large retrospective study of UVFP, most of the etio- logic findings were similar to 2 other large series, by Rosenthal et al 15 and Takano et al, 16 as shown in Table 5 . Surgical/iatrogenic causes of UVFP are more common than nonsurgical causes, and thyroid/parathyroid surgeries are implicated more often than other types of surgery but do not comprise most surgical etiologies overall. Intubation injuries and idiopathic UVFP frequencies are similar in all 3 series, and the condition occurs on the left side in nearly two-thirds of cases. Among nonsurgical cases, malignancy was the most common category, most often lung cancer. Malignancy of the lung was the most common cause in 3 previous studies. 1-3 The risk of iatrogenic injury to the recurrent laryngeal nerve in different surgical procedures has been widely Discussion Etiology of UVFP

Table 1. Etiology of Unilateral Vocal Fold Paralysis.

Etiology

No. (% of Total)

Surgery

Cardiac surgery Carotid surgery

58 (6.2) 22 (2.3) 48 (5.1) 2 (0.2) 37 (3.9) 73 (7.8) 17 (1.8) 4 (0.4) 61 (6.5) 18 (1.9)

Cervical spine surgery

Tracheostomy

Esophageal surgery

Lung surgery

Mediastinal surgery Laryngeal surgery Lateral neck surgery Parathyroid surgery Thyroid surgery Skull base surgery Intracranial surgery

140 (14.9)

18 (1.9) 24 (2.6)

Total

522 (55.6)

Malignancy

Laryngeal cancer Esophageal cancer

20 (2.1) 11 (1.2) 73 (7.8) 18 (1.9) 1 (0.1) 5 (0.5) 24 (2.6) 1 (0.1) 14 (1.5) 58 (6.2) 30 (3.2) 18 (1.9) 1 (0.1) 1 (0.1) 1 (0.1) 1 (0.1) 1 (0.1) 8 (0.9) 2 (0.2) 1 (0.1) 1 (0.1) 2 (0.2)

Lung cancer

Skull base tumor

Lymphoma

Mediastinal mass Metastatic cancer

Parotid cancer

Thyroid cancer—direct invasion

Total

167 (17.8) 124 (13.2)

Idiopathic Intubation

Trauma

CVA

Transesophageal echocardiogram

IJ catheter placement

Infected vagal nerve stimulator

Neck infection

Right skull base osteomyelitis

Neck radiation Lung radiation

Thoracic deformity Ankylosing spondylitis

Sarcoidosis

Total

938 (100.0)

Abbreviations: CVA, cerebral vascular accident; IJ, internal jugular.

presented to an outside otolaryngologist and were later referred. The median time of presentation to an outside oto- laryngologist was 2.1 months, while the median time of pre- sentation to a WUSM otolaryngologist was 9.5 months ( P \ .001). Given the very low rate of patients previously treated, we conclude that this 7.4-month difference in median is the period during which patients were observed by the outside otolaryngologist for possible recovery prior to referral to

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