Laryngoscopy of vocal fold paralysis: evaluation of consistency of clinical findings

Vocal cord movement: can it be accurately graded?

INTRODUCTION

Flexible nasendoscopy (FNE) is the principal assessment method for vocal cord movement. Because the procedure is inherently subjective it may not be possible for clinicians to grade the degree of vocal cord movement reliably. The aim of this study was to assess the accuracy and consistency of grading vocal cord movement as viewed via FNE.

METHODS

Thirty FNE videos, without sound or clinical information, were assessed by six consultant head and neck surgeons. The surgeons were asked to assess and grade right and left vocal cord movement independently, based on a five-category scale. This process was repeated three times on separate occasions. Agreement and reliability were assessed.

RESULTS

Mean overall observed inter-rater agreement was 67.7% (sd 1.9) with the five-category scale, increasing to 91.4% (sd 1.9) when a three-category scale was derived. Mean overall observed intra-rater agreement was 78.3% (sd 9.7) for five categories, increasing to 93.1% (sd 3.3) for three categories. Discriminating vocal cord motion was less reliable using the five-category scale (k = 0.52) than with the three-category scale (k = 0.68).

CONCLUSIONS

This study demonstrates quantitatively that it is challenging to accurately and consistently grade subtle differences in vocal cord movement, as proven by the reduced agreement and reliability when using a five-point scale instead of a three-point scale. The study highlights the need for an objective measure to help in the assessment of vocal cord movement.

Visual Interpretation of Vocal Fold Paralysis in Flexible Laryngoscopy Using Eye Tracking Technology

OBJECTIVES

Interpretation of laryngoscopy is an important diagnostic skill in otolaryngology. There is, however, limited understanding of the specific visual strategies used while assessing flexible laryngoscopy video. Eye-tracking technology allows for objective study of eye movements during dynamic tasks. The purpose of the present study was to explore visual gaze strategies during laryngoscopy interpretation of unilateral vocal fold paralysis (UVFP) across clinician experience from novice to expert.

METHODS

Thirty individuals were shown five flexible laryngoscopy videos, each 10 seconds long. After viewing each video, participants reported their impressions of "left vocal fold paralysis," "right vocal fold paralysis," or "no vocal fold paralysis." Eye tracking data were collected and analyzed for duration of fixation and number of fixations on select areas of interest (AOI). Diagnostic accuracy and visual gaze patterns were compared between novice, experienced, and expert groups.

RESULTS

Diagnostic accuracy among learners in the novice group was significantly lower than those in the more experienced groups (P = 0.04). All groups demonstrated similar visual gaze patterns when viewing the video with normal bilateral vocal fold mobility, spending the greatest percentage of time viewing the trachea. There were differences among groups when viewing the videos of left or right VFP, but the trachea was always in the top three structures for greatest fixation duration and highest number of fixations.

CONCLUSIONS

Eye-tracking is a novel tool in the setting of laryngoscopy interpretation. With further study it has the potential to be useful for the training of otolaryngology learners to improve diagnostic skills.

[Predictive value of strobovideolaryngoscopy, acoustic and aerodynamic measures in the prognosis of temporally unilateral vocal fold paralysis after thyroidectomy]

Objective:To investigate the strobovideolaryngoscopy, acoustic and aerodynamic characteristics of transient unilateral vocal ford paralysis（UVFP） after thyroidectomy. Methods:A retrospective analysis was made of 11 patients with temporary UVFP after thyroidectomy who were treated in Department of Otolaryngology and Head and Neck Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University from January 2013 to March 2021; 8 patients with permanent UVFP after thyroidectomy during the same period were included as a control group. The differences in baseline strobovideolaryngoscopy, acoustic and aerodynamic measures were compared between the two groups. Results:The tones of patients with temporary UVFP after thyroidectomy were all normal, and the proportions of abnormal vocal fords（vocal ford bowing, atrophy, and shortening）, ventricular adduction and glottic insufficiency were significantly lower than those of permanent UVFP patients; arytenoid cartilage stability and height mismatch of vocal ford tended to be better than permanent UVFP. The maximal phonation time（MPT） in patients with temporary UVFP was （8.5±4.1） s, which was significantly longer than （3.9±2.1） s in patients with permanent UVFP; fundamental frequency, mean airflow（MeAF） and mean subglottic pressure（SGP） were better in temporary UVFP than those in patients with permanent UVFP, but the difference did not reach statistical significance. Conclusion:None and mild glottic insufficiency, normal tone, ventricular adduction, and vocal ford appearances without vocal fold bowing, atrophy, and shortening, can be served as the predictors for the early recovery of vocal ford movement in temporary UVFP after thyroidectomy. The MPT less than 4 s, and MeAF, and SGP remarkably increased is the predictor of poor prognosis for vocal ford recovery.

Comparison between propofol and alfaxalone anesthesia for the evaluation of laryngeal function in healthy dogs utilizing computerized software

Laryngeal paralysis is a well-documented cause of upper respiratory tract obstruction in canines. Diagnosis of laryngeal paralysis is usually made by visual evaluation of laryngeal motion whilst patients are under a light-plane of anesthesia. However, in human studies of laryngeal function evaluation, it has been shown that subjective scoring can lead to significant interobserver variance, which may cause false diagnosis. In this study, we propose to introduce a more objective method of assessing laryngeal function using GlotAnTools and Tracker software to directly measure laryngeal motion in anaesthetized patients. Additionally, two anesthetic agents, alfaxalone and propofol, were compared in this study to assess their relative effect on laryngeal motion and thus their suitability for use in this diagnostic process. This study was a two-stage, cross-over, 1:1 randomization, with two active treatment arms. Ten beagles (10–18 months, five males and five females) were exposed to both anesthetic agents and laryngeal motion was recorded using videoendoscopy. GlotAnTools and Tracker software were applied to the recorded images to measure glottal gap area (A) and length (L). A normalized measure of laryngeal function–computed as A/L–was created, representing the "elongatedness" of the rima glottidis. The glottal gap area was significantly reduced in dogs receiving alfaxalone. This study objectively establishes that alfaxalone impacted laryngeal motion significantly more than propofol and confirms the capability of these computational methods to detect differences in laryngeal motion.

Vocal cord lesions classification based on deep convolutional neural network and transfer learning

PURPOSE

Laryngoscopy, the most common diagnostic method for vocal cord lesions (VCLs), is based mainly on the visual subjective inspection of otolaryngologists. This study aimed to establish a highly objective computer-aided VCLs diagnosis system based on deep convolutional neural network (DCNN) and transfer learning.

METHODS

To classify VCLs, our method combined the DCNN backbone with transfer learning on a system specifically finetuned for a laryngoscopy image dataset. Laryngoscopy image database was collected to train the proposed system. The diagnostic performance was compared with other DCNN-based models. Analysis of F1 score and receiver operating characteristic curves were conducted to evaluate the performance of the system.

RESULTS

Beyond the existing VCLs diagnosis method, the proposed system achieved an overall accuracy of 80.23%, an F1 score of 0.7836, and an area under the curve (AUC) of 0.9557 for four fine-grained classes of VCLs, namely, normal, polyp, keratinization, and carcinoma. It also demonstrated robust classification capacity for detecting urgent (keratinization, carcinoma) and non-urgent (normal, polyp), with an overall accuracy of 0.939, a sensitivity of 0.887, a specificity of 0.993, and an AUC of 0.9828. The proposed method also outperformed clinicians in the classification of normal, polyps, and carcinoma at an extremely low time cost.

CONCLUSION

The VCLs diagnosis system succeeded in using DCNN to distinguish the most common VCLs and normal cases, holding a practical potential for improving the overall diagnostic efficacy in VCLs examinations. The proposed VCLs diagnosis system could be appropriately integrated into the conventional workflow of VCLs laryngoscopy as a highly objective auxiliary method.

Diagnostic limitation of laryngostroboscopy in comparison to laryngeal electromyography in synkinesis in unilateral vocal fold paralysis

Purpose

In clinical practice, laryngo(strobo)scopy (LS) is still mainly used for diagnostics and management of unilateral vocal fold paralysis (UFVP), although only laryngeal electromyography (LEMG) can provide information on causes of vocal fold immobility, especially on possible synkinetic reinnervation after recurrent laryngeal nerve (RLN) injury. The goal of this retrospective study was the evaluation whether signs of synkinetic reinnervation in LS can be objectified in comparison to LEMG data.

Methods

Between 1/2015 and 2/2018, 50 patients with laryngostroboscopically suspected UVFP received routine LEMG examination. The LEMG findings were retrospectively compared with LS findings. The LEMG data analysis focused on the diagnosis of synkinetic reinnervation of the TA/LCA and/or PCA. The digital LS recordings were retrospectively re-evaluated by phoniatricians considering 22 selected laryngostroboscopic parameters.

Results

LEMG revealed synkinesis in 23 (46%) and absence of synkinesis in 27 (54%) patients. None of the 22 parameters showed significant association between patients with synkinetic reinnervation and LS findings. The only laryngostroboscopic parameter that was significantly associated with a silent LEMG signal compared to single fiber activity in LEMG was a length difference on the side of the UVFP (p-value 0.0001; OR 14.5 (95% CI 3.047–66.81; Sensitivity 0.5; Specificity 0.9355).

Conclusion

Our findings show that synkinesis cannot be diagnosed using only LS. This study underlines the importance of LEMG in clinical routine for detection of laryngeal synkinesis in patients with UVFP before any further therapeutic steps are initiated to avoid later therapy failure.

Medialization Laryngoplasty: A Review for Speech-Language Pathologists

Purpose The purpose of this study is to familiarize speech-language-pathologists with the current state of the science regarding medialization laryngoplasty in the treatment of voice disorders, with emphasis on current evidence-based practice, voice outcomes, and future directions for research. Method A literature review was performed in PubMed and Embase using the keywords vocal fold/cord and laryngoplasty, thyroplasty, augmentation, or laryngeal framework. Articles published between 2010 and 2020 were reviewed for data about clinical applications, technical approach, voice-related outcomes, and basic science or clinical innovations with the potential to improve patient care. A synthesis of data was performed from articles meeting the outlined search criteria. Conclusions As key members in the multidisciplinary care of voice disorders, speech-language pathologists need to be informed of current research in medialization laryngoplasty, a procedure commonly used for patients with glottic insufficiency. Advances in anesthetic technique, office-based procedures, and the development of materials with increased bio-tolerability over the past decade have led to innovations in treatment and improved patient outcomes. Recent applications of computational and bioengineering approaches have the potential to provide new directions in the refinement of currently available techniques and the improvement of patient-based treatment outcomes.

Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment

BACKGROUND

Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group.

METHODS

A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach.

RESULTS

Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery.

CONCLUSION

After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.

Guidelines for the Management of Unilateral Vocal Fold Paralysis From the Korean Society of Laryngology, Phoniatrics and Logopedics

The Korean Society of Laryngology, Phoniatrics and Logopedics appointed a task force to establish clinical practice guidelines for the management of unilateral vocal fold paralysis (UVFP). These guidelines cover a comprehensive range of management-related factors, including the diagnosis and treatment of UVFP, and provide in-depth information based on current, up-to-date knowledge. Detailed evidence profiles are provided for each recommendation. The CORE databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers, using a predefined search strategy. When insufficient evidence existed, expert opinions and Delphi questionnaires were used to fill the evidence gap. The committee developed 16 evidence-based recommendations in six categories: initial evaluation (R1–4), spontaneous recovery (R5), medical treatment (R6), surgical treatment (R7–14), voice therapy (R15), and aspiration prevention (R16). The goal of these guidelines is to assist general otolaryngologists and speech-language pathologists who are primarily responsible for treating patients with UVFP. These guidelines are also intended to facilitate understanding of the condition among other health-care providers, including primary care physicians, nurses, and policy-makers.

Preoperative Voice Characteristics in Thyroid Patients

INTRODUCTION

Thyroid surgery outcomes have evolved from mortality control strategies to morbidity control measures. Most vocal outcomes research in thyroid surgery are focused on recurrent nerve anatomic and functional preservation. However, there are likely multiple causes of vocal dysfunction in thyroid patients. We prospectively analyzed preoperative patients with thyroid disease to define preoperative vocal characteristics of this population.

OBJECTIVE

Quantify vocal and laryngeal baseline conditions in thyroid surgical patients.

METHODS

Prospective study of preoperative stroboscopy findings and vocal function assessing the correlation between thyroid disease, compressive symptoms, baseline vocal conditions and laryngoscopy results.

RESULTS

Vocal quantitative scores were positive for dysphonia in 36% of patients and the Vocal Handicap Index confirmed either slight or Moderate impairment in most patients. Stroboscopy results were abnormal in 60% of cases with no diagnoses of immobility. Correlation was established for diagnosis of cancer and the absence of symptoms.

CONCLUSIONS

These results point to a multifactorial cause for vocal impairment in thyroid surgery patients. Research on vocal impairment in thyroid surgery should not be centered exclusively on recurrent nerve neuromonitoring and functional preservation, but also on other variables that may contribute to vocal change in thyroid disease and surgery.

Comparison of arytenoid vertical height discrepancy in normal versus patients with vocal cord palsy

OBJECTIVE

Cadaveric experiments and more recently clinical data have demonstrated that patients with vertical height discrepancy between their arytenoids experience poorer voice outcomes in patients with unilateral vocal cord palsy (UVP) after medialisation laryngoplasty. However, the presence or severity of height discrepancy in normal patients without UVP has not yet been clearly defined.

STUDY DESIGN

Case-control study.

SETTING

Tertiary Australian hospitals.

SUBJECTS AND METHODS

A retrospective review was performed on patients who underwent high computed tomography imaging of the neck. Scans were assessed for discrepancy in arytenoid vertical height discrepancy and compared to a cohort with known UVP.

RESULTS

44 normal patients (50% female, mean age 57.6 ± 14.8 years) were compared to 23 patients with UVP (43.4% female, mean age 52.3 ± 14.9 years.) Normal patients were found to have a smaller height discrepancy compared to UVP patients (student's t-test,2.00 mm ± 0.00 vs 2.39 mm ± 0.72, p < .001.) CONCLUSION: This study suggests that discrepancy is pathologic, and it is plausible that this results in acoustic consequences.

The Clinical Course of Idiopathic Bilateral Vocal Fold Motion Impairment in Adults: Case Series and Review of the Literature

AIM

Steps for assessment and successful management of bilateral vocal fold motion impairment (VFMI) are (1) recognition of its presence, (2) identifying the etiology and factors restricting vocal fold motion, (3) evaluation of airway patency, and (4) establishing a management plan. No large series documenting the course and outcome of adult idiopathic bilateral VFMI has been published within the past 15 years.

METHODS

Retrospective chart review of adult patients with idiopathic bilateral VFMI at a tertiary academic center. A diagnosis was established if history, physical examination with laryngoscopy, and initial imaging excluded a cause. Records were reviewed for demographics, clinical characteristics, surgical intervention details, and length of follow-up.

RESULTS

Nine adult patients with idiopathic bilateral VFMI were identified. There were five males and four females with a mean age of 59.6 years. The mean follow-up period was 54.4 months (range, 6-111 months). Upon presentation to our laryngology service, three patients were advised observation, three patients were advised to undergo urgent tracheostomy, and three patients were advised to undergo elective surgery for airway management. By the end of the follow-up period, only four patients (4/9, 44.4%) were tracheostomy dependent, one of them was lost to follow-up after tracheostomy tub downsizing for decannulation.

CONCLUSIONS

To our best knowledge, this is the largest series so far of adult patients with idiopathic bilateral VFMI. Conservative treatment can be considered as an alternative to surgery in select cases.

Perspectives on voice treatment for unilateral vocal fold paralysis

PURPOSE OF REVIEW

Unilateral vocal fold paralysis (UVFP) is a common cause of neurogenic dysphonia resulting in glottal insufficiency. To restore glottal sufficiency and reduce the presenting dysphonia, treatment involving either surgical intervention, voice therapy or a combination of the two is typically provided. Currently, there is no consensus for the most effective voice treatment for UVFP. This results in an inability to compare current studies, and a lack of treatment effectiveness for the management of UVFP. This study aims to review the most recent literature for the management of dysphonia due to UVFP to establish the current evidence base for voice treatment options.

RECENT FINDINGS

There was found to be a lack of consistency in the rationale, selection and timing of the surgical intervention and/or voice therapy being provided for patients with UVFP.

SUMMARY

Further consensus is required for the rationale and selection of voice treatment prescriptions for the management of UVFP in order to improve treatment effectiveness and voice outcomes in patients with UVFP.

Radiotherapy for locally advanced resectable T3-T4 laryngeal cancer-does laryngeal preservation strategy compromise survival?

With the advancement of chemotherapy, a laryngeal preservation (LP) strategy was explored with the aim of improving maintenance of quality of life. Induction chemotherapy (ICT) following radiotherapy (RT) was considered a viable option because of its high initial response rate without hampering of overall survival (OS). Subsequently, concurrent chemoradiotherapy (CCRT) using CDDP became the standard of care for LP, showing the best LP ratio. For enhancing treatment intensity, ICT with taxan + CDDP + 5-FU (TPF-ICT) followed by RT showed superiority over ICT with CDDP + 5-FU (PF-ICT) followed by RT. Given that almost all randomized controlled trials investigating ICT include not only operable (endpoint, LP) but also inoperable (endpoint, OS) cases, physicians are faced with a dilemma regarding application in daily practice. In addition, increased treatment intensity causes augmentation of adverse events, which might reduce compliance. Thereafter, cetuximab, an effective drug with fewer adverse effects [bioradiotherapy (BRT)], emerged as another option. However, little evidence has confirmed its superiority over RT (or CCRT) in laryngeal cancer subpopulations. In spite of these developments, the OS of patients with laryngeal cancer has not improved for several decades. In fact, several studies indicated a decrease in OS during the 1990s, probably due to overuse of CCRT. Fortunately, the latter was not the case in most institutions. Currently, no other treatment has better OS than surgery. The eligibility criteria for LP and/or surgery largely depend upon the available expertise and experience, which differ from one institution to another. Therefore, a multidisciplinary team is required for the treatment of LP.

The reliability of flexible nasolaryngoscopy in the identification of vocal fold movement impairment in young infants

OBJECTIVE

Flexible nasolaryngoscopy (FNL) is considered the gold standard for evaluation of vocal fold mobility but there has been no data on the reliability of interpretation in the infant population. Visualization may be limited by excessive movement, secretions, or floppy supraglottic structures that prevent accurate diagnosis of vocal fold movement impairment (VFMI). We sought to evaluate the inter- and intra-rater reliability of FNL for the evaluation of VFMI in young infants.

STUDY TYPE

Case-control.

METHODS

Twenty infants were identified: 10 with VFMI and 10 normal as seen on FNL. Three pediatric otolaryngologists reviewed the video without sound and rated the presence and/or degree of vocal fold mobility. Twelve videos were repeated to assess intra-rater reliability.

RESULTS

There was substantial agreement between the reviewers regarding the identification normal vs. any type of VFMI (kappa = 0.67) but only moderate agreement regarding the degree of vocal fold movement (kappa = 0.49). Intra-rater reliability ranges from moderate to perfect agreement (kappa = 0.48-1).

CONCLUSION

FNL in infants is an extremely challenging procedure. Clinically, physicians frequently use the quality of the cry and the past medical and surgical history to help make a judgment of vocal fold movement when the view is suboptimal. These other factors, however, may bias the interpretation of the FNL. Without sound, there is only moderate inter-rater and variable intra-rater reliability for the identification of degree of movement on FNL. Otolaryngologists must be cognizant of the limitations of FNL when using it as a clinical tool or as a "gold standard" against which other modalities are measured.

Evaluation of Vocal Fold Motion Abnormalities: Are We All Seeing the Same Thing?

OBJECTIVES

Flexible laryngoscopy is the principle tool for the evaluation of vocal fold motion. As of yet, no consistent, unified outcome metric has been developed for vocal fold paralysis/immobility research. The goal of this study was to evaluate vocal fold motion assessment (inter- and intra-rater reliability) among general otolaryngologists and fellowship-trained laryngologists.

STUDY DESIGN

Prospective video perceptual analysis study.

METHODS

Flexible laryngoscopic examinations, with sound, of 15 unique patient cases (20 seconds each) were sent to 10 general otolaryngologists and 10 fellowship-trained laryngologists blinded to clinical history. Reviewers were given written definitions of vocal fold mobility and immobility and two video examples. The cases included bilateral vocal fold mobility (six), unilateral vocal fold immobility (five), and unilateral vocal fold hypomobility (four). Five examinations were repeated to determine intra-rater reliability. Participants were asked to judge if there was or there was no purposeful motion, as described by written definitions, for each vocal fold (800 tokens in total).

RESULTS

Twenty reviewers (100%) replied. Both general otolaryngologists and fellowship-trained laryngologists had an overall inter-rater reliability of 95%. Difference in inter-rater reliability between the two groups of raters was negligible: 95% for general otolaryngologists and 97.5% for fellowship-trained laryngologists. There was no variability in intra-rater reliability within either rater group (99%).

CONCLUSION

Intra- and inter-rater agreement in determining whether the patient had purposeful vocal fold motion on flexible laryngoscopic examination was excellent in both groups. This study demonstrates that otolaryngologists can consistently and accurately judge the presence and the absence of vocal fold motion.

Organ preservation with chemoradiation in advanced laryngeal cancer: The problem of generalizing results from randomized controlled trials

BACKGROUND

The primary goal of treatment in advanced laryngeal cancer is to achieve optimal oncologic outcomes while preserving function and quality of life. Combination of chemotherapy and radiation has been popularized as an alternative to surgery for patients facing total laryngectomy. However, survival analyses from large, population-based databases have not duplicated results reported from randomized trials.

METHODS

A comprehensive literature review was undertaken to try to better understand the reasons why results differ among randomized trials and population cohort studies.

RESULTS

A variety of reasons are discussed, including differences in patient staging, selection bias, complexity bias, inconsistent terminology, patient compliance and treatment expertise.

CONCLUSIONS

Personalized treatment considering all factors is critical for optimal outcomes. In general, evidence supports total laryngectomy for patients with T4 cancers. Definitive chemoradiotherapy strategies are acceptable alternatives for T3 cancers, provided that all resources for the administration of the treatment, follow-up and surgical salvage are available.

The effect of anchors on reliability of endoscopic tremor ratings

OBJECTIVES/HYPOTHESIS

The purpose of this study was to determine the effects of anchors and training on intrarater and inter-rater reliability for visual-perceptual, endoscopic tremor ratings.

STUDY DESIGN

Prospective cohort study.

METHODS

Nasoendoscopy recordings of 10 participants with a diagnosis of essential voice tremor were evaluated by five voice specialists using the Vocal Tremor Scoring System. Ratings were performed before, immediately after, and 4 weeks after implementation of a training program with anchor stimuli. Immediate and long-term post-training ratings were performed with simultaneous use of anchor samples for each rating.

RESULTS

Intrarater reliability showed significant improvement from pretraining to immediate and long-term post-training. Mean correlation coefficients (Spearman's rho) increased from 0.71 at pretraining to 0.84 and 0.90 at immediate and long-term post-training, respectively. Inter-rater reliability was not affected by training with anchors, with mean correlation coefficients ranging from 0.62 at pretraining to 0.58 and 0.64 at immediate and long-term post-training, respectively.

CONCLUSIONS

Consistent, reproducible ratings are critical for the interpretation and comparison of endoscopic tremor data. Reliability findings from this study indicate that the use of anchor samples as referents for making ordinal judgments about the severity of tremor in oropharyngeal and laryngeal regions was helpful for improving internal standards and consistency but less useful for calibrating across different raters.

LEVEL OF EVIDENCE

4 Laryngoscope, 2016 127:411-416, 2017.

Spontaneous recovery of bilateral congenital idiopathic laryngeal paralysis: systematic non-meta-analytical review

OBJECTIVES

To systematically review the frequency and time to spontaneous recovery in pediatric patients with bilateral congenital idiopathic laryngeal paralysis (BCILP).

METHODS

The databases of Medline, EMBASE, Scopus, CINAHL, Cochrane Library and Proquest Dissertations were searched for English language articles reporting on laryngeal paralysis in pediatric patients. A bibliography search of the selected studies was done to identify additional articles. We included prospective or retrospective case-series studies of children and neonates diagnosed with BCILP at age <60 days and confirmed by direct laryngoscopy, with sufficient follow up and objective assessment for recovery. Two authors independently extracted the data and assessed the quality of each study. Discrepancies were resolved by consensus and adjudication by a third author.

RESULTS

Of the 4229 articles identified by the search, only one study met our inclusion criteria. The study was a retrospective case series, and was of low quality. The mean age at diagnosis was fourteen days. Sixty-five percent of the patients recovered spontaneously, and the mean time to recovery was twenty-five months. Tracheostomy was performed in 71% of the patients.

CONCLUSIONS

The available literature is of low quality and provides weak evidence on the natural history of BCILP in pediatric population.

Factors associated with the improvement of vocal fold movement: an analysis of LEMG and laryngeal CT parameters

The aim of this study is to elucidate the relationship of laryngeal electromyography (LEMG) and computed tomographic (CT) parameters to improve the prognosis of recurrent laryngeal nerve injury. 22 patients clinically suspected of having recurrent laryngeal nerve injury were examined with LEMG and CT studies. Bilateral thyroarytenoid (TA) muscles were examined and findings were interpreted by a single blind technique. Laryngeal CT image analysis of the ventricle dilation symmetry determined TA muscle atrophy. Finally, a follow-up laryngoscopic examination determined improvement of vocal fold movement. Ventricle dilation symmetry and the dichotomized TA muscle atrophy parameter significantly relate to the improvement of vocal fold movement (χ(2)=4.029, P=0.039, and χ(2)=3.912, P=0.048, respectively). When the severity of vocal fold impairment was classified as severe TA muscle atrophy or none/discrete MUAP recruitment, it was found to significantly relate with the improvement of vocal fold movement (χ(2)=6.712, P=.010). From this study, image analysis of the ventricle dilation symmetry to determine the severity of TA muscle atrophy shows promise for the improved prognosis of vocal fold immobility.

Vocal fold insufficiency: medialization laryngoplasty vs calcium hydroxylapatite microspheres (Radiesse Voice®)

CONCLUSION

The choice of technique will depend on the glottic gap observed by stroboscopy, the alteration of the Voice Handicap Index (VHI) and the recorded values of harmonics-to-noise ratio (HNR), jitter and shimmer, and the general health, age and underlying pathology. There are statistically significant differences between the values of VHI, shimmer and jitter in favour of those cases operated on within 6 months of diagnosis. Alternatives are discussed.

OBJECTIVES

This study analysed and compared the functional, morphological and acoustic results, after surgery, through the techniques of medialization thyroplasty and infiltration of biomaterials to correct incomplete closure of the glottis.

METHODS

A total of 21 patients with dysphonia due to vocal fold insufficiency (13 women and 8 men) and ages ranging between 30 and 65 years (mean age 40.84, SD 12.5) were evaluated. The material used for augmentation surgery consisted of calcium hydroxylapatite microspheres. Measurements (VHI, jitter, shimmer and HNR) were performed before surgery and at 6 and 24 months post-intervention.

RESULTS

Overall, statistically significant differences were observed relating to measurements (p < 0.01) and surgical techniques (p < 0.05) analyzed. In particular, these differences were located in pairs pre-surgery - 6 months post-surgery and pre-surgery - post 24 months, in the four variables, and between the two techniques used in jitter (p = 0.008), HNR (p = 0.045) and VHI (p = 0.035).

Interrater agreement of nasal endoscopy for chronic rhinosinusitis

BACKGROUND

Nasal endoscopy is a routine, important diagnostic tool in the evaluation of chronic rhinosinusitis (CRS). Although the procedure is ideally "objective," the subjective nature of endoscopy interpretation and lack of standardization are potential limitations. The goal of this study was to examine the interrater agreement of various categories of nasal endoscopy findings in patients undergoing evaluation for CRS.

METHODS

Fourteen patients (28 sides) with CRS underwent clinical evaluation, SNOT-22, sinus computed tomography (CT), and digital video nasal endoscopy. Five academic rhinologists blindly reviewed the endoscopies for structural anatomic issues, inflammatory rhinosinusitis findings, and atypical lesions. Statistical comparison of the endoscopy interpretations was performed using the unweighted Fleiss' kappa statistic (K(f) ).

RESULTS

The mean Lund-Mackay CT scan score was 7.8 (standard deviation [SD] 4.9) and the mean SNOT-22 score was 35.8 (SD 22.7). Significant variability was noted among the raters with respect to the various categories of nasal endoscopy findings. The overall levels of interrater agreement for the various categories were as follows: "almost perfect" for atypical lesions (K(f) = 0.912); "substantial" for nasal polyps (K(f) = 0.693); "moderate" for nasal discharge (K(f) = 0.422) and mucosal inflammatory changes of the middle turbinate (K(f) = 0.413); and "fair" for edema of the middle meatus (K(f) = 0.214), obstruction by nasal septum deviation (K(f) = 0.240), and obstruction by the middle turbinate (K(f) = 0.276).

CONCLUSION

Significant variability was noted in the interrater agreement for nasal endoscopy findings in this study, with relatively limited agreement on some of the key findings of the procedure. Additional investigation and standardization of nasal endoscopy interpretation is required to improve the clinical utility of the procedure.