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Comment & Response
March 26, 2020

Unilateral Vocal Fold Immobility—More Common Than We Think?

Author Affiliations
  • 1The William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, London, England
JAMA Otolaryngol Head Neck Surg. Published online March 26, 2020. doi:10.1001/jamaoto.2020.0142

To the Editor We thank Campbell et al1 for their study analyzing the association of potential clinical factors with the development of unilateral vocal fold immobility (UVFI) following prolonged (>12 hours) mechanical ventilation. In their study, they report a UVFI incidence rate of 7% and established an association between inpatient hypotension, preadmission vascular disease, coronary artery disease, and use of vasopressors with development of UVFI.1

Unilateral vocal fold immobility is a major cause of dysphonia. Alongside symptoms of dysphagia, dyspnea, and ineffective coughing, it can cause considerable patient distress.2 A greater understanding of its incidence and pathophysiology in high-risk cohorts would go far in the implementation of future preventative measures. This study1 does well in delineating the possible associations of the aforementioned factors with UVFI. Yet, the underpowered nature of the study should prompt further efforts of investigation using a larger and more diverse cohort.

In the study, a cutoff of 36 hours postextubation was used for study enrollment. Although highly unlikely, it is possible that this 36 hour cutoff might fail to capture patients with a delayed-type reaction. Given the variability in the presentation and persistence of UVFI postextubation,3 it would be interesting to see the differences elucidated when patients are endoscopically evaluated at multiple time points, eg, 24, 36, and 48 hours postextubation.

We appreciate the detailed analysis of patient characteristics in Table 1.1 Despite the lack of significant association between patient body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) and UVFI, the differences in median BMI for patients with UVFI and those without (34.7 vs 29.6) does present an avenue for further study. Working with the running hypothesis of recurrent laryngeal nerve injury, it is possible that a high BMI will have significant bearing on the development of UVFI given the higher prevalence of intubation injuries and complications in this cohort.4 It would be interesting to see if a significant association is found when a larger cohort of patients are studied.

Although efforts were made to highlight the different intubating clinicians, it would be even more beneficial to report the level of experience of each personnel. Unsurprisingly, less experienced personnel face greater difficulties in intubating patients. The wealth of evidence that poorly performed intubation increases the risk of morbidity and mortality5 should therefore make this an important point of consideration.

We thank the authors for their contribution and look forward eagerly to further work on this topic.

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Article Information

Corresponding Author: Zheyuan Chen, BSc, The William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Charterhouse Square, London EC1M 6BQ, England (z.chen@smd19.qmul.ac.uk).

Published Online: March 26, 2020. doi:10.1001/jamaoto.2020.0142

Conflict of Interest Disclosures: None reported.

References
1.
Campbell  BR, Shinn  JR, Kimura  KS,  et al.  Unilateral vocal fold immobility after prolonged endotracheal intubation.  JAMA Otolaryngol Head Neck Surg. 2019;146(2):160-167. doi:10.1001/jamaoto.2019.3969PubMedGoogle ScholarCrossref
2.
Williamson  AJ, Shermetaro  C. Unilateral Vocal Cord Paralysis. In:  StatPearls. Treasure Island, FL: StatPearls Publishing; 2019. https://www.ncbi.nlm.nih.gov/books/NBK535420/. Accessed December 25, 2019.
3.
Shin  YH, An  DA, Choi  WJ, Kim  YH.  Unilateral vocal cord paralysis following a short period of endotracheal intubation anesthesia.  Korean J Anesthesiol. 2013;65(4):357-358. doi:10.4097/kjae.2013.65.4.357PubMedGoogle ScholarCrossref
4.
Cierniak  M, Sobczak  R, Timler  D, Wieczorek  A, Borkowski  B, Gaszyński  T.  The degree of intubation difficulties and the frequency of complications in obese patients at the hospital emergency department and the intensive care unit: case-control study.  Medicine (Baltimore). 2016;95(52):e5777. doi:10.1097/MD.0000000000005777PubMedGoogle Scholar
5.
Crewdson  K, Lockey  DJ, Røislien  J, Lossius  HM, Rehn  M.  The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis.  Crit Care. 2017;21(1):31. doi:10.1186/s13054-017-1603-7PubMedGoogle ScholarCrossref
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