Original Research

Otolaryngology–
Head and Neck Surgery

Unilateral Vocal Fold Paralysis and Risk of 1–8

Ó American Academy of
Otolaryngology—Head and Neck
Pneumonia: A Nationwide Population- Surgery Foundation 2018
Reprints and permission:
Based Cohort Study sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599818756285
http://otojournal.org

Ming-Shao Tsai, MD1,2, Yao-Hsu Yang, MD, PhD2,3,4,5,

Chia-Yen Liu, MS2, Meng-Hung Lin, PhD2, Geng-He Chang, MD1,
Yao-Te Tsai, MD1, Hsueh-Yu Li, MD6,7, Ying-Huang Tsai, MD8,9,
and Cheng-Ming Hsu, MD1,5,10

Sponsorships or competing interests that may be relevant to content are dis- Received August 28, 2017; revised December 11, 2017; accepted
closed at the end of this article. January 10, 2018.

Abstract

Objective. To investigate pneumonia risk among patients with
unilateral vocal fold paralysis (UVFP).
Study Design. Retrospective population-based cohort study.
Setting. This study used data from the National Health Insurance
Research Database of Taiwan, a nationwide population-based
database.
Subjects and Methods. A total of 419 patients newly diagnosed
with UVFP between January 1, 1997, and December 31, 2013,
were identified from the Longitudinal Health Insurance
Database 2000, a nationally representative database of 1 mil-
lion randomly selected patients. Moreover, 1676 patients with-
out UVFP were matched to patients with UVFP at a 1:4 ratio
based on age, sex, socioeconomic status, urbanization level,
and site-specific cancers. Patients were followed up until death
or the end of the study period (December 31, 2013). The pri-
mary outcome was the occurrence of pneumonia.
Results. The cumulative incidence of pneumonia was signifi-
cantly higher for patients with UVFP than those without UFVP
(P \ .001). The adjusted Cox proportional hazard model
showed that UVFP was significantly associated with a higher
incidence of pneumonia (hazard ratio, 1.97; 95% CI, 1.35-2.86;
P \ .001). Subgroup analyses demonstrated that UVFP was an
independent risk factor of pneumonia for 4 subgroups: young
(18-50 years), older (51 years), male, and cancer.
Conclusion. This is the first nationwide population-based
cohort study to investigate the association between UVFP
and pneumonia. The findings indicate that UVFP is an inde-
pendent risk factor of pneumonia. Given the study results,
physicians should be aware of the potential for pneumonia
occurrence following UVFP.
Keywords
unilateral vocal fold paralysis, pneumonia, dysphagia, chok-
ing, aspiration, infection, risk factor
P
neumonia is a leading infectious cause of hospitaliza-
tion and death among adults in the United States and
worldwide.1,2 In the United States, the annual inci-
dence of pneumonia has been reported as 24.8 cases per
10,000 adults, with the highest incidence rates observed for
adults aged .65 years.1 Approximately 5% to 15% of
patients with community-acquired pneumonia (CAP) are in
1
Department of Otolaryngology–Head and Neck Surgery, Chiayi Chang
Gung Memorial Hospital, Chiayi, Taiwan
2
Health Information and Epidemiology Laboratory of Chang Gung Memorial
Hospital, Chiayi, Taiwan
3
Institute of Occupational Medicine and Industrial Hygiene, College of
Public Health, National Taiwan University, Taipei, Taiwan
4
Department of Traditional Chinese Medicine, Chiayi Chang Gung
Memorial Hospital, Chiayi, Taiwan
5
School of Traditional Chinese Medicine, College of Medicine, Chang Gung
University, Taoyuan, Taiwan
6
Department of Otolaryngology–Head and Neck Surgery, Linkou Chang
Gung Memorial Hospital, Taoyuan, Taiwan
7
Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan,
Taiwan
8
Division of Pulmonary and Critical Care Medicine, Department of
Respiratory Care, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
9
Department of Respiratory Therapy, College of Medicine, Chang Gung
University, Taoyuan, Taiwan
10
Graduate Institute of Clinical Medical Sciences, College of Medicine,
Chang Gung University, Taoyuan, Taiwan
This study was based in part on data from the National Health Insurance
Research Database provided by the National Health Insurance
Administration, Department of Health, and managed by the National
Health Research Institutes, Taiwan. The interpretation and conclusions con-
tained herein do not represent those of the NHI Administration,
Department of Health, or National Health Research Institutes.
Corresponding Author:
Cheng-Ming Hsu, MD, Department of Otolaryngology–Head and Neck
Surgery, Chiayi Chang Gung Memorial Hospital, No. 6, Sec West, Jiapu Rd,
Puzi-City, Chiayi County 61363, Taiwan, Republic of China.
Email: scm0031@cgmh.org.tw
2 Otolaryngology–Head and Neck Surgery

the elderly population, and the majority of nursing home–

acquired pneumonia cases are caused by aspiration.3-5
Unilateral vocal fold paralysis (UVFP) occurs when 1
vocal fold is paralyzed in the paramedian or lateral position
with extremely limited movement. UVFP with dysphonia
and dysphagia comorbidity may lead to pneumonia due to
aspiration, which has potentially life-threatening conse-
quences.6,7 Based on the results of fiberoptic endoscopy and
stroboscopy evaluation, previous studies reported that UVFP
increases the odds of aspiration.8-13 To the best of our
knowledge, the long-term risk of pneumonia among patients
with UVFP remains unknown. Therefore, this study investi-
gated whether UVFP is a risk factor of pneumonia.

Methods
Data Source and Study Design
This nationwide cohort study used data from the population-
based National Health Insurance Research Database
(NHIRD). The National Health Insurance (NHI) program,
implemented on March 1, 1995, is a single-payer compul-
sory universal health insurance plan that currently covers all
types of health care services for .99% of all citizens of
Taiwan.14,15 This high coverage rate enables studies based
on the NHIRD to be nationwide population-based studies.
The NHIRD contains comprehensive information on pre-
scription details, clinic visits, surgical procedures, and diag-
nostic codes.16,17 The International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-
CM) and International Classification of Diseases, Ninth
Revision, Procedure Coding System are used to define the
diagnostic and procedure codes in the NHIRD, respec-
tively.18 This database has been used for various scientific
studies, and the information on diagnosis, hospitalization,
and prescription use included in the database has been
proven to be of high quality.19 The present study retrieved
data from the Longitudinal Health Insurance Database 2000
(LHID2000), a representative database of 1 million patients
randomly selected from the 2000 Registry of Beneficiaries
of the NHIRD by using a systematic sampling method; the
LHID2000 contains all claims data recorded from 1996 to
2013.20 According to reports from the Taiwan National
Health Research Institutes, in the LHID2000, no statistically
significant differences were observed for age, sex, socioeco-
nomic status, or urbanization level between the sample
group and all enrollees of the NHI program.21
This study was approved by the Institutional Review Board
of Chang Gung Medical Foundation (No. 201700214B1). To
ensure privacy, the personal information of all patients
included in the NHIRD is deidentified. The NHI Admini-
stration and Institutional Review Board of Chang Gung
Medical Foundation guarantee the confidentiality of the
personal and health information of all patients.
Study and Comparison Cohorts
Figure 1 presents a flowchart of the patient enrollment pro-
cess for the study cohort. Patients aged 18 years who were
Figure 1. Flowchart for identification and enrollment of study
patients. LHID2000, Longitudinal Health Insurance Database 2000;
UVFP, unilateral vocal fold paralysis.
newly diagnosed with UVFP (ICD-9-CM code 478.32)
between January 1, 1997, and December 31, 2013, were
identified from the NHIRD and included in the study
cohort. We included only patients with UVFP if the ICD-9-
CM codes for this condition occurred in the inpatient setting
or in 3 ambulatory care claims. These strict inclusion cri-
teria enabled us to confirm diagnoses of UVFP. The date of
enrollment was defined as the date of initial diagnosis of
UVFP.
Patients without UVFP were randomly selected from the
same data sets and included in the comparison cohort.
These patients were also matched to patients with UVFP at
a 1:4 ratio based on age, sex, socioeconomic status, urbani-
zation level, and site-specific cancers. For the comparison
cohort, the start of follow-up was defined as the date of the
first visit to a medical facility in the year of enrollment. In
both cohorts, patients diagnosed with pneumonia within 1
month before enrollment were excluded from this study to
avoid interference from the antecedent infection.
Outcome and Covariate Measurements
Patients were followed up until death or the end of the
study period (December 31, 2013). Death was defined as
the withdrawal of the patient from the NHI program.14 The
primary outcome was the occurrence of pneumonia (ICD-9-
CM codes 480-486, 507.0-507.8).
Patients’ sociodemographic characteristics, including age,
sex, socioeconomic status, and urbanization level, were obtained
Tsai et al 3

from their initial enrollment data. Cross-checking for dysphagia Table 1. Baseline Characteristics of Study Patients.
(ICD-9-CM codes 438.12 and 787.20-787.29) among pneumo- UVFP Non-UVFP
nia patients was performed. The comorbidities associated with
pneumonia were assessed and retrieved from ambulatory and Variables n % n % P Value
inpatient claims data. The comorbidities were as follows:
asthma (ICD-9-CM code 493), chronic obstructive pulmonary Total 419 1676
disease (ICD-9-CM codes 491, 492, 496), diabetes mellitus Sex 1.000
(ICD-9-CM code 250), stroke (ICD-9-CM codes 430-438), heart Male 234 55.9 936 55.9
failure (ICD-9-CM codes 402.01, 402.11, 402.91, 404.01, Female 185 44.2 740 44.2
404.03, 404.11, 404.13, 404.91, 404.93, 428), cancer (ICD-9- Age, y 1.000
CM codes 140-208), and chronic kidney disease (CKD) (ICD-9- 18-50 191 45.6 764 45.6
CM codes 582, 583, 585, 586, 588, 403.01, 403.11, 403.91, 51 228 54.4 912 54.4
404.02, 404.03, 404.12, 404.13, 404.92, 404.93, v45.1). We Urbanized level 1.000
included these comorbidities in the analysis if they occurred in 1 (City) 143 34.4 572 34.4
the inpatient setting or in 3 ambulatory care claims. Each 2 168 40.1 672 40.1
comorbidity was analyzed as a binominal variable. 3 71 17.0 284 17.0
4 (Villages) 37 8.8 148 8.8
Statistical Analyses Income (NTD) 1.000
To compare the comorbidities between the UVFP and com- 0 77 18.4 308 18.4
parison cohorts, descriptive statistics including categorical 1-15,840 77 18.4 308 18.4
and continuous data were analyzed with the Pearson chi- 15,841-25,000 177 42.2 708 42.2
square test and independent Student t test, respectively. The 25,001 88 21.0 356 21.0
Kaplan-Meier method was used to calculate the cumulative Pneumonia 52 12.4 119 7.1 \.001
incidence rates of pneumonia in both cohorts, and the log- Comorbidities
rank test was used to analyze the differences between the Asthma 60 14.3 140 8.4 \.001
curves. The adjusted hazard ratio for matched-pair pneumo- CKD 52 12.4 105 6.3 \.001
nia occurrence was estimated with a Cox proportional COPD 104 24.8 215 12.8 \.001
hazard model by including a matching variable, which Diabetes mellitus 92 22.0 287 17.1 .022
accounted for the matching based on age, sex, socioeco- Heart failure 44 10.5 104 6.2 .002
nomic status, urbanization level, and site-specific cancer. To Stroke 87 20.8 227 13.5 \.001
test the potential effects of modifiers, we conducted sub- Cancer 112 26.7 448 26.7 1.000
group analyses stratified by sex, age, and cancer. All statis- Abbreviations: CKD, chronic kidney disease; COPD, chronic obstructive
tical analyses were conducted with SAS 9.4 (SAS Inc, Cary, pulmonary disease; NTD, New Taiwan dollar; UVFP, unilateral vocal fold
North Carolina) and statistical significance was set at 2- paralysis.
sided P \ .05.

Results
This study enrolled 419 patients with UVFP and 1676
patients without UVFP. After matching based on sex, age,
socioeconomic status, and site-specific cancer, the results
showed that patients in the UVFP cohort were more likely
to have pneumonia than were those in the comparison
cohort (Table 1). Cross-checking for dysphagia codes
among pneumonia patients indicated that 25% (13 of 52) of
the patients with pneumonia in the UVFP cohorts had dys-
phagia and 4.2% (5 of 119) of the patients with pneumonia
in non-UVFP cohorts had dysphagia (P \ .001). In our
study, the mean (SD) observation durations were 3.96 (3.08)
and 4.54 (2.98) years for the UVFP and comparison cohorts,
respectively.
Based on the Kaplan-Meier method without accounting
for competing risk events, the cumulative incidence of
pneumonia was significantly higher in the UVFP cohort
than the comparison cohort (P \ .001; Figure 2). The 1-,
4-, and 8-year cumulative incidence rates of pneumonia
were 6.54% and 1.09%, 13.3% and 5.15%, and 18.8% and
12.9% in the UVFP and comparison cohorts, respectively.
Specifically, sex-, age-, and cancer-stratified analyses
revealed that patients with UVFP had significantly higher
risk of pneumonia than patients without UVFP for men
but not women (Figure 3A), for the 18- to 50-year and
51-year age groups (Figure 3B), and for patients with
or without cancer (Figure 3C), respectively.
Table 2 presents the results of multivariate analysis
comparing the risk of pneumonia between the UVFP and
comparison cohorts. As shown in Table 2, after adjustment
for comorbidities, the risk of pneumonia was significantly
higher in the UVFP cohort (adjusted hazard ratio, 1.97; 95%
CI, 1.35-2.86; P \ .001) than in the comparison cohort. In
addition, chronic obstructive pulmonary disease, diabetes
mellitus, and stroke were the predictors of pneumonia. In
Table 3, all subgroup analyses are adjusted for confoun-
ders, and the data were stratified according to potential con-
founders. Moreover, the effects of UVFP remained
significant for men but not women, for the 18- to 50-year
and 51-year age groups, and for patients with cancer but
not those without cancer.
4 Otolaryngology–Head and Neck Surgery
Figure 2. Cumulative incidence of pneumonia in patients with and
without unilateral vocal fold paralysis (UVFP). Patients with UVFP
had a significantly higher cumulative incidence of pneumonia than
those without UVFP.
Discussion
To the best of our knowledge, this study is the first to inves-
tigate the risk of pneumonia among patients with UVFP.
The results showed that the risk of pneumonia was signifi-
cantly higher in the UVFP cohort (adjusted hazard ratio,
1.97; 95% CI, 1.35-2.86) than in the comparison cohort,
independent of confounders including asthma, chronic
kidney disease, chronic obstructive pulmonary disease, dia-
betes mellitus, heart failure, stroke, and cancer. In the
UVFP cohort, the 1-, 4-, and 8-year death-adjusted cumula-
tive incidence rates of pneumonia were estimated as 6.54%,
13.3%, and 18.8%, respectively.
To investigate the long-term incidence of pneumonia
after UVFP, conducting a single-center study with an ade-
quate sample size and sufficient follow-up period may not
be feasible. Using the nationwide population-based data-
base, we identified adequate numbers of UVFP and pneu-
monia cases in Taiwan with minimal selection bias, because
all health care services are covered by the NHI program.
Based on the power of the large sample size, our study
found strong evidence for the higher occurrence of pneumo-
nia for patients with UVFP. The log-rank test results indi-
cated a significantly higher incidence rate of pneumonia in
the UVFP cohort than in the comparison cohort. In our
study, the mean observation duration was 4.42 years, which
was sufficient for observing the trends and changes in the
risk of pneumonia in both cohorts. To elucidate the
sequence of events, we excluded patients who had been
diagnosed with pneumonia within 1 month before UVFP
diagnosis. To consider the effects of potential confounders,
we used a matching Cox model after adjustment for comor-
bidities to compare the outcomes between the study and
comparison cohorts. Moreover, subgroup analyses were per-
formed to confirm that the effect of UVFP was consistent.
We found that patients with UVFP had a higher risk of
pneumonia than those without UVFP across all subgroups,
and this finding was statistically significant for men, for the
18- to 50-year and 51-year age groups, and for patients
with cancer. Accordingly, our findings support that UVFP is
an independent risk factor of pneumonia.
UVFP is related to unilateral 10th nerve palsy and iso-
lated recurrent laryngeal nerve injury. Thus, patients with
UVFP exhibit ipsilateral vocal fold paralysis but also supra-
glottic laryngeal and pharyngeal abnormalities with reduced
laryngeal elevation, weak pharyngeal stripping wave, and
pharyngeal retention, all of which may cause aspiration.8
Leder et al reported that individuals with UVFP have 2.50-
times higher odds of aspirating that do those without
UVFP.8 Another study reported that dysphagia in patients
with UVFP is demonstrated during flexible endoscopic eva-
luation by pooling, spillage, penetration, and aspiration.12
Moreover, 1 study reported that patients with UVFP exhibit
an alteration of bolus transit through the upper esophageal
sphincter and have no adaptation in swallowing timing
related to the increase in bolus volume.11 These studies
verify the increased risk of dysphagia among patients with
UVFP and provide possible mechanisms.
Aspiration pneumonia, defined as the misdirection of
oropharyngeal or gastric contents into the larynx and lower
respiratory tract, can be caused by dysphagia, stroke, and
neurodegenerative diseases.22,23 Previous studies indicated
the association between dysphagia and aspiration pneumo-
nia. Park et al reported that aspiration and penetration
observed during a videofluoroscopic swallow study and
high-resolution manometry were predictors of aspiration
pneumonia among patients with dysphagia.23 Almirall et al
reported that oropharyngeal dysphagia is a risk factor for
CAP among elderly patients.24 Moreover, dysphagia related
to stroke and Parkinson’s disease is a risk factor of pneumo-
nia.25,26 The aforementioned studies verified that dysphagia
is associated with a higher risk of pneumonia. However, our
study is the first to report the increasing risk of pneumonia
after UVFP. Thus, our findings extend existing knowledge
about the complications of UVFP.
The 8-year cumulative incidence rate of pneumonia was
.12% in the non-UVFP group, suggesting that a consider-
able portion of pneumonia cases were related to CAP rather
than aspiration pneumonia. Information on the etiology of
pneumonia was unavailable in the population-based data-
base; thus, we could not confirm the definite etiology of
pneumonia (aspiration pneumonia or CAP). We conducted
cross-checking for dysphagia codes in the records of
patients with pneumonia to determine whether their pneu-
monia was related to aspiration. The results revealed that
although patients with pneumonia in the UVFP group were
more likely to have dysphagia than those in the non-UVFP
group (25% vs 4.2%, P \ .001), only 25% of patients with
pneumonia in the UVFP group had dysphagia. The afore-
mentioned results suggest that a considerable portion of
pneumonia cases in the UVFP and non-UVFP groups may
be related to CAP. Nevertheless, the prevalence of
Tsai et al 5

Figure 3. Cumulative incidence of pneumonia in (A) men and women, (B) 18- to 50-year and 51-year age groups, and (C) patients with
and without cancer. Stratified analyses revealed a significantly higher risk among patients with unilateral vocal fold paralysis (UVFP) than
among those without UVFP for men but not women, 18- to 50-year and 51-year age groups, and patients with cancer but not those with-
out cancer.

dysphagia in the UVFP group is much lower than that of
previous studies, which reported a dysphagia prevalence of
50% to 69% among patients with UVFP.27-29 This discre-
pancy may be attributed to an underestimation of dysphagia
among patients with UVFP in our study; that is, the NHIRD
provides only ICD-9 diagnosis codes, not the original medi-
cal records containing detailed symptoms and signs.
However, we could not confirm this, given the setting and
design of our study—a natural limitation of many large-
scale databases. Additional prospective studies are required
to clarify this critical issue.
The weakened coughing force in patients with UVFP
may contribute to the increasing risk of pneumonia. A pre-
vious study reported that half of healthy adults aspirate
small amounts of oropharyngeal secretions during sleep.3,30
Healthy adults with forceful coughing and normal immune
6 Otolaryngology–Head and Neck Surgery

Table 2. Multivariable Cox Proportional Hazard Model for the Associations of Pneumonia with UVFP and Covariates.
Variables Crude HR 95% CI P Value Adjusted HR 95% CI P Value

UVFP vs Non-UVFP
Non- UVFP 1.00 Reference 1.00 Reference
UVFP 2.41 1.69-3.43 \.001 1.97 1.35-2.86 \.001
Comorbidities
Asthma 1.76 1.08-2.85 .022 1.14 0.65-1.99 .653
CKD 1.55 0.89-2.70 .125 0.99 0.53-1.83 .968
COPD 2.24 1.52-3.29 \.001 1.63 1.05-2.54 .029
Diabetes mellitus 2.05 1.38-3.05 \.001 1.78 1.16-2.74 .009
Heart failure 1.99 1.20-3.30 .008 1.38 0.79-2.43 .263
Stroke 2.14 1.44-3.18 \.001 1.69 1.11-2.58 .015
Abbreviations: CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; HR, hazard ratio; UVFP, unilateral vocal fold paralysis.

Table 3. Subgroup Analysis of the Association of Pneumonia with UVFP according to Potential Confounders.
Variables Crude HR 95% CI P Value Adjusted HR 95% CI P Value

Sex
Male 2.52 1.69-3.77 \.001 2.18 1.42-3.35 \.001
Female 2.08 0.99-4.38 .055 1.55 0.63-3.84 .340
Age, y
18-50 2.76 1.27-6.02 .011 2.77 1.16-6.66 .023
51 2.33 1.57-3.46 \.001 1.82 1.19-2.78 .006
Cancer
Yes 2.28 1.38-3.77 .001 2.21 1.31-3.71 .003
No 2.37 1.43-3.92 \.001 1.46 0.81-2.62 .205
Abbreviations: HR, hazard ratio; UVFP, unilateral vocal fold paralysis.

mechanisms can prevent themselves from pneumonia.
However, for patients with UVFP who have an impaired
coughing force, the aspiration of even a small amount of secre-
tions without obvious symptoms of dysphagia may lead to
pneumonia. Haemophilus influenzae and Streptococcus pneu-
moniae colonize the naso- or oropharynx and may cause
aspiration pneumonia and CAP.31 The term aspiration pneu-
monia refers to the presence of radiographically evident pneu-
monia among patients with an increased risk of aspiration.3
However, pneumonia occurring among patients with UVFP
who have a weakened coughing force but not obvious dyspha-
gia might be diagnosed as having CAP instead of aspiration
pneumonia. In this situation, the differential diagnosis of
aspiration pneumonia and CAP becomes more difficult for
patients with UVFP.
In the present study, the risk of pneumonia was signifi-
cantly higher in the UVFP cohort than the comparison
cohort. Specifically, in subgroup analysis, significantly higher
risks were found for men but not women, possibly because of
the following reasons. In Taiwan, men are far more likely
than women to smoke (odds ratio, 17.90; 95% CI, 15.40-
20.80).32 Smoking may reduce the innate defense mechan-
isms in the airways and lead to an increased risk of pneumo-
nia and respiratory tract infection.33,34 Once aspiration occurs
in patients with UVFP who are smokers, the risk of pneumo-
nia may further increase.
We observed a higher risk of pneumonia in the UVFP
cohort than in the comparison cohort across all subgroups. In
addition, in subgroup analysis, significantly higher risks were
found in the cancer subgroup but not in the noncancer subgroup.
Previous studies reported that pneumonia risks are higher for
patients with head and neck cancer, esophageal cancer, lung
cancer, and hematologic malignancies.35 Cancer- and cancer
treatment–related derangements of lung architecture, mucositis,
impaired airway protection or swallow function, disparate
mechanisms of neutropenia, and malnutrition all contribute to
increased pneumonia risks.35 Thus, for patients with cancer,
UVFP may further increase the risk of pneumonia.
Given the results of the present study, patients with
UVFP who are at a high risk of pneumonia should be identi-
fied. Physicians should pay closer attention to the potential
for pneumonia occurrence among patients with UVFP to
enable its early diagnosis; they should also routinely per-
form chest radiography and laboratory evaluations and regu-
larly monitor patients with UVFP to detect related
symptoms and signs of infection. Moreover, our study
reported a higher incidence of pneumonia in the UVFP
cohort versus the comparison cohort in the first year after
Tsai et al
UVFP diagnosis (1-year cumulative incidence: 6.54% vs
1.09%). This finding implies that early treatment of UVFP may
serve as a strategy for preventing pneumonia. Bhattacharyya
et al reported that early vocal cord medialization for patients
with a new onset of UVFP after thoracic surgery can reduce
pulmonary complications.36 A previous study reported that for
patients with UVFP and dysphagia, a significant improvement
in swallowing was achieved following medialization laryngo-
plasty.28 Another study reported that voice therapy had marked
benefits for patients with UVFP and dysphagia.37 However,
not all patients with paralysis require immediate medialization.
Therefore, fiberoptic endoscopic evaluation of swallowing is a
tool that physicians can use to determine which patients most
urgently require this procedure. In this study, sufficient evi-
dence was not provided to indicate whether the treatment of
UVFP decreased the risk of pneumonia. Thus, additional stud-
ies are required to evaluate the treatment outcomes.
Our study had several limitations. First, the diagnoses of
UVFP and pneumonia recorded in administrative claims
data may not be as accurate as diagnoses made in clinical
prospective settings. Second, to clarify their individual roles
in pneumonia, the definite etiologies of UVFP (iatrogenic,
malignancy, idiopathic, and level of nerve injury) and pneu-
monia (bacterial, viral, or aspiration) could not be clearly
distinguished on the basis of ICD-9-CM codes in the
NHIRD. Third, laryngoscopy images and stroboscopy
videos are not available in the database; thus, we could not
correlate the severity of UVFP with the occurrence of pneu-
monia. Fourth, chest radiographic, blood culture, and
sputum culture data are not available. As such, the metho-
dology of this study cannot distinguish between aspiration
pneumonia and CAP. Finally, our study was retrospective.
Additional prospective clinical trials are necessary to eluci-
date the causal relationship between UVFP and pneumonia
and the related treatment outcomes.
Conclusion
This is the first nationwide population-based cohort study to
investigate the association between UVFP and pneumonia.
The findings indicate that UVFP is an independent risk
factor of pneumonia. Given the study results, physicians
should be aware of the potential for pneumonia occurrence
following UVFP. Further studies are required to evaluate
the effects of treatment (including medialization laryngo-
plasty, injection laryngoplasty, voice therapy, and dysphagia
therapy) on pneumonia risk.
Acknowledgments
We thank the Health Information and Epidemiology Laboratory
of Chang Gung Memorial Hospital, Chiayi, Taiwan (CLRPG6-
G0041), for the comments and assistance with data analysis. We
acknowledge Wallace Academic Editing for editing this
manuscript.
Author Contributions
Ming-Shao Tsai, conception and design of the project; acquisition,
analysis and interpretation of the data; drafting, critical revision
7
and final approval of the manuscript; Yao-Hsu Yang, acquisition,
analysis and interpretation of the data; critical revisions and final
approval of the manuscript; Chia-Yen Liu, analysis and interpreta-
tion of the data; critical revision and final approval of the manu-
script; Meng-Hung Lin, analysis and interpretation of the data;
critical revision and final approval of the manuscript; Geng-He
Chang, conception and design of the project; drafting and final
approval of the manuscript; Yao-Te Tsai, conception and design
of the project; drafting and final approval of the manuscript;
Hsueh-Yu Li, conception of the project; critical revision and final
approval of the manuscript; Ying-Huang Tsai, conception of the
project; drafting, critical revision and final approval of the manu-
script; Cheng-Ming Hsu, conception and design of the project;
drafting, critical revision and final approval of the manuscript.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: The study was financially supported by grants
from the Chang Gung Memorial Hospital, Chiayi, Taiwan,
Republic of China (CGRPG6G0011).
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