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Systematic Review/Meta-analysis Systematic Review with or without Meta-analysis

Otolaryngology– Head and Neck Surgery 1–12 American Academy of Otolaryngology–Head and Neck 2022,Vol. 168(1) 14–25 © 2022 American Academy of Otolaryngology–Head and Neck Surgery Foundation. DOI:10.1177/01945998211072832 http://otojournal.org Surgery Foundation 2022 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/01945998211072832 http://otojournal.org

Dysphagia Outcomes Following Surgical Management of Unilateral Vocal Fold Immobility: A Systematic Review and Meta-analysis

Michael Coulter, MD 1 , Kastley Marvin, MD 2 , Matthew Brigger, MD, MPH 3,4 , and Christopher M. Johnson, MD 5

fold immobility, paralysis, adult, surgical management, laryn geal reinnervation

Abstract Objective. To assess dysphagia outcomes following surgical man agement of unilateral vocal fold immobility (UVFI) in adults. Data Sources. Ovid MEDLINE, Embase, Web of Science, and Cochrane Central. Review Methods. A structured literature search was utilized, and a 2-researcher systematic review was performed follow ing PRISMA guidelines. Extractable data were pooled, and a quantitative analysis was performed with a random effects model to analyze treatment outcome and complications by procedure. Results. A total of 416 publications were screened and 26 met inclusion criteria. Subjects encompassed 959 patients with UVFI who underwent 916 procedures (n = 547, injec tion laryngoplasty; n = 357, laryngeal framework surgery; n = 12, laryngeal reinnervation). An overall 615 were identi fied as having dysphagia as a result of UVFI and had individu ally extractable outcome data, which served as the basis for a quantitative meta-analysis. In general, dysphagia outcomes after all medialization procedures were strongly positive. Quantitative analysis demonstrated a success rate estimate of 90% (95% CI, 75%-100%) for injection laryngoplasty and 92% (95% CI, 87%-97%) for laryngeal framework surgery. The estimated complication rate was 7% (95% CI, 2%-13%) for injection laryngoplasty and 15% (95% CI, 10%-20%) for laryngeal framework surgery, with minor complications pre dominating. Although laryngeal reinnervation could not be assessed quantitatively due to low numbers, qualitative analy sis demonstrated consistent benefit for a majority of patients for each procedure. Conclusion. Dysphagia due to UVFI can be improved in a majority of patients with surgical procedures intended to improve glottal competence, with a low risk of complications. Injection laryngoplasty and laryngeal framework surgery appear to be efficacious and safe, and laryngeal reinnervation may be a promising new option for select patients. Keywords dysphagia, outcomes, injection laryngoplasty, medialization, thyroplasty, aspiration, systematic review, unilateral vocal

Received September 2, 2021; accepted December 20, 2021.

E tiologies of unilateral vocal fold immobility (UVFI) are diverse: iatrogenic causes account for the highest proportion, and most cases are from nonthyroid neck surgery (ie, anterior cervical spine approach and carotid endarterectomy). 1 Other causes include idiopathic, inflamma tory disorders, trauma, and stroke or other central neurologic conditions. In addition to voice symptoms, UVFI can disrupt the complex dynamics of swallowing and airway protection resulting in dysphagia, inadequate cough, and risk of aspira tion. 2,3 While the majority of outcomes research on vocal fold medialization procedures focuses on voice outcomes, avail able data specific to swallowing symptoms suggest that 55% 1 Department of Otolaryngology–Head and Neck Surgery, Naval Hospital Camp Pendleton, California, USA 2 Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center Camp Lejeune, North Carolina, USA 3 Division of Pediatric Otolaryngology, Rady Children’s Hospital–San Diego, San Diego, California, USA 4 Department of Otolaryngology–Head and Neck Surgery, University of California–San Diego, San Diego, California, USA 5 Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, California, USA This article was presented at the 2021 AAO-HNSF Annual Meeting and OTO Experience; October 5, 2021; Los Angeles, California. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the US government. M.C., K.M., and C.J. are active duty military service members. This work was prepared as part of their official duties. Title 17, USC, §105 provides that copyright protection under this title is not avail able for any work of the US government. Title 17, USC, §101 defines a US gov ernment work as a work prepared by a military service member or employee of the US government as part of that person’s official duties. Corresponding Author: Michael Coulter, MD, Department of Otolaryngology–Head and Neck Sur gery, Naval Hospital Camp Pendleton, 200 Mercy Circle, Oceanside, CA 92055. Email: Michael.Jack.Coulter@gmail.com