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Wang F, Yiu EML. Predicting Dysphonia by Measuring Surface Electromyographic Activity of the Supralaryngeal Muscles. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2024; 67:740-752. [PMID: 38315579 DOI: 10.1044/2023_jslhr-23-00110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
PURPOSE This study set out to investigate whether individuals with dysphonia, as determined by either self-assessment or clinician-based auditory-perceptual judgment, exhibited differences in perilaryngeal muscle activities using surface electromyography (sEMG) during various phonatory tasks. Additionally, the study aimed to assess the effectiveness of sEMG in identifying dysphonic cases. METHOD A total of 77 adults (44 women, 33 men, Mage = 30.4 years) participated in this study, with dysphonic cases identified separately using either a 10-item Voice Handicap Index (VHI-10) or clinician-based auditory-perceptual voice quality (APVQ) evaluation. sEMG activities were measured from the areas of suprahyoid and sternocleidomastoid muscles during prolonged vowel /i/ phonations at different pitch and loudness levels. Normalized root-mean-square value against the maximal voluntary contraction (RMS %MVC) of the sEMG signals was obtained for each phonation and compared between subject groups and across phonatory tasks. Additionally, binary logistic regression analysis was performed to determine how the sEMG measures could predict the VHI-10-based or APVQ-based dysphonic cases. RESULTS Participants who scored above the criteria on either the VHI-10 (n = 29) or APVQ judgment (n = 17) exhibited significantly higher RMS %MVC in the right suprahyoid muscles compared to the corresponding control groups. Although the RMS %MVC value from the right suprahyoid muscles alone was not a significant predictor of self-evaluated dysphonic cases, a combination of the RMS %MVC values from both the right and left suprahyoid muscles significantly predicted APVQ-based dysphonic cases with a 69.66% fair level. CONCLUSIONS This study found that individuals with dysphonia, as determined by either self-assessment or APVQ judgment, displayed more imbalanced suprahyoid muscle activities in voice production compared to nondysphonic groups. The combination of the sEMG measures from both left and right suprahyoid muscles showed potential as a predictor of dysphonia with a fair level of confidence. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.25112804.
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Affiliation(s)
- Feifan Wang
- School of Humanities, Shanghai Normal University, Shanghai, China
- Voice Research Laboratory, The University of Hong Kong, Pokfulam
| | - Edwin M-L Yiu
- Voice Research Laboratory, The University of Hong Kong, Pokfulam
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Vontela S, Balouch B, Bress E, Brennan MJ, Alnouri G, Martha VV, Sataloff RT. Vocal Fold Paresis and Voice Outcomes following Vocal Fold Mass Excision. J Voice 2024; 38:225-230. [PMID: 34474936 DOI: 10.1016/j.jvoice.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To correlate the surgical results of vocal fold mass excision with pre-operative existence of vocal fold paresis. METHODS Data were collected on 66 patients who underwent excision of benign vocal fold masses from 2015 to 2020. The pre- and post-operative strobovideolaryngoscopy (SVL) examinations for all patients included were evaluated blindly by three otolaryngologists using THE Voice-Vibratory Assessment with Laryngeal Imaging (VALI) Form for scar severity, mucosal wave, free edge contour, glottal closure, and phase closure. The success of mass excision surgery was determined based on the presence of the following criteria post-operatively: 1) improved mucosal wave motion 2) improved phase closure or glottic closure 3) improved free edge contour and 4) lack of worsening of vocal fold scar severity. Surgery was considered successful if 3 or 4 criteria were met, partially successful if 1 or 2 criteria were met, and unsuccessful if no criteria were met. The percent recruitment of the thyroarytenoid, posterior cricoarytenoid (PCA), and cricothyroid muscles were used evaluated the severity of paresis as mild (70-99% recruitment), moderate (40-60% recruitment), or severe (0-39% recruitment). VHI-10 scores were used as subjective measures of pre- and post-operative voice. RESULTS Sixty-six patients (26 male, 40 female) were included in this study, with a mean age of 37.25 ± 16.6 (range 18-78). Twelve patients had no evidence of VF paresis noted during the initial clinical evaluation; and 52 patients had paresis and had undergone laryngeal EMG. 81% of these patients had mild paresis, 12.8% had moderate paresis, and 5.8% had severe paresis. Based on pre- and post-operative strobovideolaryngoscopy, there was improvement in mucosal wave in 44.9% of cases, improvement of phase or glottic closure in 85.4% of cases, improved free edge contour in 95.5% of cases, and worsening of scar in 38.5% of cases. 39.6% of surgeries were fully successful, 33.3% of surgeries were partially successful, and 27.1% were not successful. There was a significant correlation between female gender and vocal fold paresis (P = 0.048). Paresis severity did not correlate with complete or partial surgical success (P = 0.956), pre-operative VHI-10 scores (P = 0.519), post-operative VHI-10 scores (P = 0.563), or strobovideolaryngoscopy parameters. Unilateral and bilateral paresis did not correlate with any other parameter of surgical success (P >0.05). CONCLUSION This study suggests that there is no correlation between pre-operative vocal fold paresis and voice outcomes after mass excision surgery, that the majority of mass excision surgeries (72.9%) are successful based on improvement in stroboscopic parameters, and that the proportion of patients with moderate and severe paresis is consistent across all laryngeal nerves.
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Affiliation(s)
- Swetha Vontela
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Bailey Balouch
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Eli Bress
- Department of Otolaryngology, Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Matthew J Brennan
- Department of Otolaryngology, Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Ghiath Alnouri
- Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Vishnu V Martha
- Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Robert T Sataloff
- Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine, Lankenau Institute for Medical Research, Philadelphia, PA, USA.
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Heman‐Ackah YD, Ivey CM, Alexander R. Options for treatment of a small glottic gap. Laryngoscope Investig Otolaryngol 2023; 8:720-729. [PMID: 37342105 PMCID: PMC10278110 DOI: 10.1002/lio2.1060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/01/2023] [Accepted: 03/20/2023] [Indexed: 06/22/2023] Open
Abstract
Background Glottic insufficiency, or glottic gap as it is commonly called, is a common cause of dysphonia, producing symptoms of soft voice, decreased projection, and vocal fatigue. The etiology of glottic gap can occur from issues related to muscle atrophy, neurologic impairment, structural abnormalities, and trauma related causes. Treatment of glottic gap can include surgical and behavioral therapies or a combination of the two. When surgery is chosen, closure of the glottic gap is the primary goal. Options for surgical management include injection medialization, thyroplasty, and other methods of medializing the vocal folds. Methods This manuscript reviews the current literature regarding the options for treatment of glottic gap. Discussion This manuscript discusses options for treatment of glottic gap, including the indications for temporary and permanent treatment modalities; the differences between the available materials for injection medialization laryngoplasty and how they affect the vibratory function of the vocal folds and vocal outcome; and the evidence that supports an algorithm for treatment of glottic gap. Level of Evidence 3a-Systematic review of case-control studies.
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Affiliation(s)
- Yolanda D. Heman‐Ackah
- Department of Otolaryngology‐Head and Neck SurgeryUF Health JacksonvilleJacksonvilleFloridaUSA
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Ranjbar PA, Maxwell PJ, Balouch B, Yam C, Alnouri G, Sataloff RT. The Relationship Between Vocal Fold Mobility Disorders and Ineffective Esophageal Motility. J Voice 2023:S0892-1997(23)00071-1. [PMID: 37087373 DOI: 10.1016/j.jvoice.2023.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE Deglutition, speech production, and airway protection are extraordinarily complex, interrelated functions that are coordinated, in large part, by the motor and sensory innervation of CN X. Previous studies assessing the relationship between neurogenic voice disorders and dysphagia have focused on the risk of aspiration due to glottic insufficiency and the association of vocal fold hypomobility (VFH) with systemic neurologic disease. The purpose of this study was to investigate the relationship between VFH disorders and ineffective esophageal motility (IEM). METHODS Adult voice patients who underwent laryngeal electromyography (LEMG) and dual 24-hour pH impedance with high-resolution manometry (HRM) testing were included in the study. Subjects were assigned to one of two groups based on the presence or absence of moderate-to-severe RLN and/or SLN VFH (Mo-SLNH/RLNH) using results from six muscle LEMG tests. In subjects with Mo-SLNH/RLNH, there was 0-60% muscle recruitment on LEMG, whereas control subjects in the non-Mo-SLNH/RLNH group demonstrated 61-100% muscle recruitment. Analysis of mild-to-severe VFH (80% muscle recruitment or less) was also performed in a similar manner. The prevalence of IEM, defined using Chicago Classification Version 4.0 (CCv4.0), was compared between groups, as were HRM parameters. RESULTS One hundred sixty-two subjects were included (37.7% male/62.3% female, mean age of 43.88 ± 17.285). No differences in IEM prevalence were found when stratifying for cases of mild-to-severe VFH. However, there was significantly higher percentage of IEM in those with Mo-SLNH/RLNH. Mo-SLNH/RLNH subjects demonstrated higher rates of weak swallows and inefficient swallows, as well as lower IBP and UES residual pressures on HRM. CONCLUSIONS Patients with Mo-SLNH/RLNH demonstrated a significantly higher prevalence of IEM. Those with mild-to-severe VFH did not. Higher rates of ineffective and weak swallows, and lower IBP and UES residual pressures among Mo-SLNH/RLNH subjects suggest a possible connection between Mo-SLNH/RLNH and IEM disorders. These manometric differences were more prominent with sub-stratification of the Mo-SLNH/RLNH group by IEM. Additional research is advised.
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Affiliation(s)
| | - Philip J Maxwell
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Bailey Balouch
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Christopher Yam
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Ghiath Alnouri
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.
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Maxwell PJ, Ranjbar PA, Mishra V, Yam C, Alnouri G, Lyons K, Paknezhad H, Sataloff RT. Assessing the Prevalence and Associated Risk Factors for Presbylarynx in the Elderly Laryngology Population. J Voice 2023:S0892-1997(23)00099-1. [PMID: 37015843 DOI: 10.1016/j.jvoice.2023.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/07/2023] [Accepted: 03/07/2023] [Indexed: 04/06/2023]
Abstract
OBJECTIVE The primary objective of this study was to assess the prevalence of presbylarynx and its associated features in an elderly population representative of patients seen in a tertiary care laryngology practice. The secondary objective of this study was to compare laryngeal electromyography (LEMG) findings, coexisting VF conditions, medical history, surgical history, medication use, and other parameters between patients with and without presbylarynx. METHODS Adult voice patients aged 60 years and older who underwent strobovideolaryngoscopy were included in the study. Patients were assigned to one of two groups based on the majority (≥2/3) agreement of three blinded authors' (GA, KL, and HP) graded examinations of strobovideolaryngoscopy (SVL) videos for findings consistent with presbylarynx (atrophic vocal folds [VFA], vocal fold bowing [VFB], vocal process prominence [VPP] and anterior glottic insufficiency [GI]). Patient demographics, medical history, surgical history, medication use, laboratory results, and SVL videos were compiled. Statistical analysis was performed using SPSS 28.0.0.0 (IBM, Armonk, NY). All tests were performed two-tailed, and a P-value of less than 0.05 was considered statistically significant. RESULTS One hundred sixty-four patients (84 female/80 male, mean age of 68.397 ± 4.947 years) were included in this study. The prevalence of presbylarynx was 52.4% (n = 86) in the study population. The mean age of patients in the presbylarynx group was significantly higher than the nonpresbylarynx group. Additionally, there were significantly more males than females in the presbylarynx group. The presbylarynx group also was found to have a higher proportion of ACE inhibitor (ACEi) use. Further, laboratory results revealed a significantly higher proportion of patients with elevated thyroid stimulating hormone (TSH) levels in the presbylarynx group. Conversely, patients in the nonpresbylarynx group were found to have a significantly higher rate of levothyroxine use. On SVL, patients in the nonpresbylarynx cohort were found to have a significantly higher proportion of benign vocal fold lesions and vocal fold paresis. However, LEMG testing revealed no statistically significant differences in muscle recruitment between groups. Men with presbylarynx were found to have a significantly higher proportion of VFB and VPP compared to women with presbylarynx. CONCLUSION This retrospective study investigated the prevalence and risk factors associated with presbylarynx in patients representative of those treated by laryngologists. Signs consistent with presbylarynx are observable even in the presence of coexisting VF conditions. Older age, elevated TSH, the use of ACEi, and male gender was associated with signs of presbylarynx on SVL. Of those diagnosed with presbylarynx, males were identified as having higher proportions of VFB and VPP compared to females. More education regarding presbylarynx and further studies to improve standardization of the criteria for its diagnosis, as well as its relationship with other VF conditions, are encouraged to improve management of the aging voice.
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Affiliation(s)
- Philip J Maxwell
- Drexel University College of Medicine, Philadelphia, PA, United States
| | | | - Vibhuti Mishra
- Drexel University College of Medicine, Philadelphia, PA, United States
| | - Christopher Yam
- Drexel University College of Medicine, Philadelphia, PA, United States
| | - Ghiath Alnouri
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Karen Lyons
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Hassan Paknezhad
- Department of Otolaryngology - Head and Neck Surgery, Geisinger Commonwealth School of Medicine, Danville, PA, United States
| | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Lankenau Institute for Medical Research, Philadelphia, Pennsylvania.
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Chen IM, Yeh PY, Hsieh YC, Chang TC, Shih S, Shen WF, Chin CL. 3D VOSNet: Segmentation of endoscopic images of the larynx with subsequent generation of indicators. Heliyon 2023; 9:e14242. [PMID: 36923825 PMCID: PMC10009724 DOI: 10.1016/j.heliyon.2023.e14242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 02/24/2023] [Accepted: 02/26/2023] [Indexed: 03/06/2023] Open
Abstract
Video laryngoscope is available for visualizing the motion of vocal cords and aid in the assessment of analyzing the larynx-related lesion preliminarily. Laryngeal Electromyography (EMG) needs to be performed to diagnose the factors of vocal cord paralysis, which may cause patient feeling unwell. Thus, the problem is the lack of credible larynx indicators to evaluate larynx-related diseases in the department of otolaryngology. Therefore, this paper aims to propose a 3D VOSNet model, which has the characteristics of sequence segmentation to extract the time-series features in the video laryngoscope. The 3D VOSNet model can keep the time-series features of three images before and after of the specific image to achieve translation and occlusion invariance, which explicitly signifies that our model can segment and classify each item in the video of laryngoscopy not affected by extrinsic causes such as shaking or occlusion during laryngoscope. Numerical results revealed that the testing accuracy rates of the glottal, right vocal cord, and the left vocal cord are 89.91%, 94.63%, and 93.48%, respectively. Our proposed model can segment glottal and vocal cords from the sequence of laryngoscopy. Finally, using the proposed algorithm computes six larynx indicators, which are the area of the glottal, area of vocal cords, length of vocal cords, deviation of length of vocal cords, and symmetry of the vocal cords. In order to assist otolaryngologists in staying credible and objective when making decisions without any doubt during diagnosis and also explaining the clinical symptoms of the larynx such as vocal cord paralysis to patients after diagnosis, our proposed algorithm provides otolaryngologists with explainable indicators (X-indicators).
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Affiliation(s)
- I-Miao Chen
- Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan
| | - Pin-Yu Yeh
- Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan
| | - Ya-Chu Hsieh
- Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan
| | - Ting-Chi Chang
- Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan
| | | | - Wen-Fang Shen
- Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan
| | - Chiun-Li Chin
- Department of Medical Informatics, Chung Shan Medical University, Taichung, Taiwan
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Pueringer J, Brennan M, Weinsheim T, Sataloff RT. Does the Severity of Vocal Fold Paresis on Laryngeal Electromyography Correlate With Radiographic Findings on Cross Sectional Imaging? J Voice 2023:S0892-1997(23)00023-1. [PMID: 36775753 DOI: 10.1016/j.jvoice.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVES Unilateral vocal fold paresis or paralysis (UVFP) is a condition for which radiographic evaluation and laryngeal electromyography (LEMG) are valuable to evaluate severity of injury and direct treatment plans. Despite extensive research involving findings suggestive of UVFP with radiographic imaging, no study has attempted to determine which findings suggestive of UVFP on imaging are clinically significant and suggest a need for intervention. The purpose of this study was to evaluate whether the severity of vocal fold paresis/paralysis affects the likelihood of encountering radiographic findings suggestive of UVFP. We also aimed to determine which findings suggestive of UVFP on imaging were clinically significant and were associated with surgical intervention. MATERIALS AND METHODS A retrospective chart review was conducted of patients who had been diagnosed with unilateral vocal fold paresis or paralysis and had been evaluated by CT scan and/or magnetic resonance imaging and laryngeal electromyography (EMG) between the dates of January 1, 2017 and January 9, 2018. Fisher's exact testing with Monte Carlo Simulation was utilized to determine statistical significance of identified relationships. Univariate analysis was conducted to assess for individual relationships between imaging results and the potential predictor variables. Chi square analysis was conducted with the various categorical variables to assess for any potential relationships to imaging results. Statistical significance was determined utilizing chi square analysis. RESULTS After data collection, 130 patients were included in the study population. Of the 112 patients with documented MRI results, 17% had a reported imaging abnormality suggestive of true vocal fold paresis or paralysis (VFP). Of the 71 patients with documented CT Neck results, 15.4% had an abnormality potentially concerning for true VFP. The average decrease in recruitment of the right and left SLN was 23.8% and 26.1%, respectively. The average decrease in recruitment of the right and left RLN was 37.3% and 57.78%, respectively. Seventy four percent of patients who exhibited abnormal MRI were found to have isolated SLN weakness, and 21% of patients were found to have a combined SLN and ipsilateral RLN weakness. In patients with abnormal CT scans 45% were found to have isolated SLN weakness, and 35% were found to have a combined SLN and RLN weakness. MRI imaging again failed to display any significant degree of paresis. However, abnormal CT results displayed severe CN X paresis in 36.84% vs 1.96% in normal scans. The chance of an abnormal MRI and CT result was 2.78 and 5.55 times greater, respectively, for each increase in the degree of severity of CN X paresis. When looking at the ability of imaging to predict the chance of a patient undergoing surgery, 34.8% of patients with an abnormal MRI underwent surgery compared to just 14.61% of those with normal scans. For CT scans, 35% of patients with an abnormal scan underwent surgery, compared with only 15.69% with normal imaging. When pooled, over 33% of patients with any abnormal imaging underwent a laryngeal procedure compared to 13% of patients with normal imaging. CONCLUSIONS There is a relationship between severity of vocal fold paresis found on laryngeal EMG and likelihood of detection on imaging. While CT was more likely to find characteristics of UVFP than MRI, patients who had an abnormal finding on either modality were more likely to undergo surgical intervention. These findings highlight the importance of early referral of patients with abnormal laryngeal imaging to an otolaryngologist for evaluation and possible intervention.
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Affiliation(s)
- John Pueringer
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | - Matthew Brennan
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA
| | | | - Robert T Sataloff
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA; Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA.
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Quindlen CE, Alnouri G, Sataloff RT. Safety of Laryngeal Electromyography and Repetitive Stimulation. J Voice 2023:S0892-1997(22)00398-8. [PMID: 36725410 DOI: 10.1016/j.jvoice.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Laryngeal Electromyography (LEMG) is a procedure used to assess electrical signals from laryngeal muscles. It is considered to be the gold standard test for examining vocal fold paresis/paralysis. Repetitive stimulation studies, which usually are performed at the time of LEMG, can aid in assessment of neuromuscular function. Electromyography poses risks to the patient due to the use of electricity and needles. The purpose of this paper was to evaluate the safety of LEMG and discuss the possible complications. METHODS This was a retrospective review of patients from January 2015 through February 2022. Information from patient charts included age, sex, chief complaint, past medical history, family medical history, medications, social history, strobovideolaryngoscopy results, type of paresis, professional voice user status, presence of pacemaker, laryngeal electromyography and repetitive stimulation study results, and reported complications. Complications were considered to be anything that differed from the norm. Pain was included as a complication. Data were analyzed for relationships and significance. RESULTS Five hundred patients were included. Eighteen of the 500 (3.6%) experienced complications. Four (2.1%) males and 14 (4.5%) females experienced complications. Nine of the 18 (50%) reported pain after the procedure, 1 (5.56%) had excessive bleeding (controlled with pressure), 5 (27.78%) reported voice changes, and 3 (16.67%) experienced difficulty with completion of the procedure. No patients with pacemakers or patients taking anticoagulants had complications, but repetitive stimulation studies were not performed on patients with pacemakers. CONCLUSIONS LEMG and repetitive stimulation studies are safe and effective procedures to examine laryngeal muscles. Repetitive stimulation studies are not recommended for patients with pacemakers.
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Affiliation(s)
| | - Ghiath Alnouri
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA; Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, USA.
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Marshall C, Balchander D, Alnouri G, Sataloff RT. The Use of Laryngeal Electromyography to Determine Surgical Success Following Anastomosis and Implantation Reinnervation Surgeries for Vocal Fold Paralysis: A Systematic Review. J Voice 2022:S0892-1997(22)00383-6. [PMID: 36517328 DOI: 10.1016/j.jvoice.2022.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The goal of this systematic review is to elucidate an evidence-based review of the benefit of laryngeal electromyography (LEMG) in determining surgical success following reanastamosis and implantation reinnervation surgery for treating vocal fold paralysis. METHODS We searched the following databases: PubMed, Embase and MEDLINE from inception to September 2022. Articles that included postoperative LEMG as a tool to evaluate patients after surgery for vocal fold paralysis were included. RESULTS A total of 203 studies were identified, 106 were read in full, and 11 that met the inclusion criteria were systematically reviewed. CONCLUSION The available evidence suggests that postoperative LEMG data is consistent with visual, perceptual, and acoustic analysis and therefore is a reliable tool in determining surgical success. LEMG provides both qualitative and quantitative evaluation, rather than the qualitative evaluation provided by standard methods, which yields additional parameters that more effectively and definitively characterize percent of muscle reinnervation at each stage and timeline the patient's recovery.
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Affiliation(s)
- Camryn Marshall
- Department of Otolaryngology, Head and Neck Surgery, Charles E. Schmidt College of Medicine at Florida Atlantic University, Boca Raton, Florida
| | - Divya Balchander
- Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ghiath Alnouri
- Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Robert T Sataloff
- Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine, Lankenau Institute for Medical Research, Philadelphia, Pennsylvania.
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Sciancalepore PI, Anzivino R, Petrone P, Petrone D, Quaranta N. Clinical usefulness of transcutaneous laryngeal ultrasonography in otolaryngology practice during COVID-19 pandemic: a literature review. J Ultrasound 2022; 26:1-12. [PMID: 36094753 PMCID: PMC9466352 DOI: 10.1007/s40477-022-00720-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/10/2022] [Indexed: 11/29/2022] Open
Abstract
As a consequence of the outbreak of SARS-CoV-2, the clinical practice of otolaryngologists underwent profound transformations. Non-aerosol-generating procedures have been researched and implemented. Transcutaneous laryngeal ultrasonography (TLUSG) provides a rapid and noninvasive method to assess laryngeal function and can support the management of laryngeal disorders. With the aim of investigating the clinical usefulness of TLUSG in otolaryngology practice, a review of the literature published on PubMed, Cochrane Library and Ovid/ Medline databases was performed up to March 2022. 38 studies were eligible to be included in the review. The selected papers were divided into six topics of interest: evaluation of vocal cords function, diagnosis of laryngeal disorders in infants and children, evaluation of swallowing disorders, assessment of laryngeal cancer and other laryngeal lesions, ultrasound-guided cricothyroidotomy, ultrasound-guided laryngeal electromyography. The results of this review demonstrated that TLUSG, applied to ENT practice, can be a valid method for dynamic laryngeal assessment and airway management, since it is time-efficient, non invasive, well tolerated and easily performed.
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Affiliation(s)
| | - Roberta Anzivino
- Department of Otorhinolaryngology, Di Venere Hospital, ASL BA, Bari, Italy
| | | | - Domenico Petrone
- Department of Otorhinolaryngology, Di Venere Hospital, ASL BA, Bari, Italy
| | - Nicola Quaranta
- Otolaryngology Unit, Department of BMS, Neuroscience and Sensory Organs, University of Bari "Aldo Moro", Bari, Italy
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Liu L, Ma Y, Saleh E, Qiu T, Zhuang P. Exploring the Clinical Characteristics of Superior Laryngeal Nerve Injury. J Voice 2022:S0892-1997(22)00113-8. [PMID: 35718699 DOI: 10.1016/j.jvoice.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES To observe the cases of superior laryngeal nerve injury along with summarizing and analyzing its clinical characteristics. METHODS A total of 14 patients with unilateral superior laryngeal nerve injury (SLN) diagnosed by laryngeal electromyography (LEMG) in our department from 2018 to 2020 were collected as SLN injury group. A total of 14 healthy subjects with normal laryngeal electromyography were recruited as normal group matched by age and sex. The etiology and LEMG of the SLN injury group were analyzed, and the video stroboscopic manifestations of SLN injury group and normal group were compared to see the characteristic video stroboscopic manifestations of SLN injury. RESULTS The most common causes of SLN injury were surgery and idiopathic etiology. Compared with normal group, the most frequent video stroboscopic manifestations of SLN injury group were vocal fold dyskinesia. Abnormal video stroboscopic manifestations occurred in normal group except larynx deviation, epiglottic petiole deviation, and dyskinesia. There was a significant difference between the two groups in various abnormal video stroboscopic manifestations (P < 0.05). Time limit widening was the most common manifestation of LEMG. CONCLUSIONS Vocal fold dyskinesia was a prominent finding in SLN injury, laryngeal deviation and epiglottic petiole deviation were relative specific signs of SLN injury. Vocal fold bowing combined with shortening will contribute to the diagnosis of SLN injury. There were no specific diagnostic signs for SLN injury, clinicians need further LEMG for a firm diagnosis.
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Affiliation(s)
- Liying Liu
- Department of Voice, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Yanli Ma
- Department of Voice, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Eyad Saleh
- Division of Otolaryngology, Head and Neck Surgery, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Ting Qiu
- Department of Neurology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Peiyun Zhuang
- Department of Voice, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.
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Martínez-Martínez M, García-López I, Santiago-Pérez S. Vocal fold immobility with normal LEMG: A range of possibilities. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2022; 73:77-81. [PMID: 35397827 DOI: 10.1016/j.otoeng.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/01/2020] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this paper is to study the etiology of vocal fold immobility with non-pathological LEMG. METHODS A retrospective study was performed on patients who presented with vocal fold immobility and underwent LEMG from 2009 to 2017. Those patients with normal LEMG findings were selected. The different causes of vocal fold impairment were studied. RESULTS Of the 120 patients included in this study, 15 had a normal LEMG recording. The different etiologies of vocal fold immobility were idiopathic, central nervous system damage, iatrogenic, and external compression. CONCLUSIONS Vocal fold immobility and vocal fold paralysis are not equal terms. Vocal fold immobility with normal LEMG has a heterogeneous group of causes. It is not correct to assume that the major cause of immobility in patients with normal LEMG is always cricoarytenoid joint fixation.
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Affiliation(s)
- Marta Martínez-Martínez
- Department of Otolaryngology, IdiPAZ Health Research Institute, La Paz University Hospital, Madrid, Spain.
| | - Isabel García-López
- Department of Otolaryngology, IdiPAZ Health Research Institute, La Paz University Hospital, Madrid, Spain
| | - Susana Santiago-Pérez
- Department of Clinical Neurophysiology, Hospital Universitario La Paz, Madrid, Spain
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Martínez-Martínez M, García-López I, Santiago-Pérez S. Vocal fold immobility with normal LEMG: A range of possibilities. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2021; 73:S0001-6519(21)00033-9. [PMID: 34148655 DOI: 10.1016/j.otorri.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/09/2020] [Accepted: 12/01/2020] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The objective of this paper is to study the etiology of vocal fold immobility with non-pathological LEMG. METHODS A retrospective study was performed on patients who presented with vocal fold immobility and underwent LEMG from 2009 to 2017. Those patients with normal LEMG findings were selected. The different causes of vocal fold impairment were studied. RESULTS Of the 120 patients included in this study, 15 had a normal LEMG recording. The different etiologies of vocal fold immobility were idiopathic, central nervous system damage, iatrogenic, and external compression. CONCLUSIONS Vocal fold immobility and vocal fold paralysis are not equal terms. Vocal fold immobility with normal LEMG has a heterogeneous group of causes. It is not correct to assume that the major cause of immobility in patients with normal LEMG is always cricoarytenoid joint fixation.
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Affiliation(s)
- Marta Martínez-Martínez
- Department of Otolaryngology, IdiPAZ Health Research Institute, La Paz University Hospital, Madrid, Spain.
| | - Isabel García-López
- Department of Otolaryngology, IdiPAZ Health Research Institute, La Paz University Hospital, Madrid, Spain
| | - Susana Santiago-Pérez
- Department of Clinical Neurophysiology, Hospital Universitario La Paz, Madrid, Spain
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Leclerc AA, Munin MC, Smith LJ, Rosen CA. Abnormal Laryngeal Electromyography Findings in Asymptomatic Adults Across the Age Spectrum. Laryngoscope 2020; 131:2065-2069. [PMID: 33125187 DOI: 10.1002/lary.29213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Laryngeal electromyography (LEMG) is a diagnostic tool for patients with suspected neurogenic abnormalities of the larynx. LEMG is often used with the assumption that any abnormality is symptom-/disease-related. We sought to determine the prevalence of abnormal LEMG findings in a group of healthy asymptomatic adults across a large age spectrum. STUDY DESIGN Open, prospective study, gender-match and age balanced by decade. METHODS Forty-six healthy participants (age 20-78) underwent LEMG, including 178 muscles. Participants had no history of voice problems, normal VHI-10, and normal flexible laryngoscopy. Qualitative and quantitative LEMG (bilateral) were performed involving the thyroarytenoid-lateral cricoarytenoid muscle complex (TA-LCA) and cricothyroid (CT) muscles. LEMG parameters included evaluation for fibrillation potentials, sharp waves, reduced recruitment, polyphasic potentials, electrical synkinesis, and measurement of turns per second. RESULTS Of participants, 4% had at least one abnormal qualitative finding (slightly reduced recruitment or two to three discrete polyphasic potentials). There were no findings of fibrillation potentials or sharp waves. There were no abnormal qualitative findings in the CT muscles tested. Of participants, 16% had at least one abnormal synkinesis finding. LEMG qualitative abnormalities and quantitative abnormalities do not appear to correlate with gender or age. CONCLUSION Abnormal qualitative and quantitative LEMG findings were uncommon and minor in severity in our group of asymptomatic healthy adults. The likelihood of abnormal LEMG results in asymptomatic adults was 2.2% for qualitative findings, 9.3% for synkinesis, and 5.4% for turns/s. LEVEL OF EVIDENCE 3 Laryngoscope, 131:2065-2069, 2021.
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Affiliation(s)
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Libby J Smith
- UPMC Voice Center, Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Clark A Rosen
- UCSF Voice and Swallowing Center, Division of Laryngology, Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco School of Medicine, San Francisco, California, U.S.A
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Song SA, Santeerapharp A, Alnouri G, Park J, Sataloff RT, Franco RA. The Poor Validity of Asymmetric Laryngoscopic Findings in Predicting Laterality in Vocal Fold Paresis. J Voice 2020; 36:853-858. [PMID: 33077320 DOI: 10.1016/j.jvoice.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/06/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine the laryngoscopic findings most predictive of laterality in vocal fold paresis in patients with known RLN and/or SLN paresis by laryngeal electromyography (LEMG). STUDY DESIGN Blinded, prospective video perceptual analysis study. METHODS Patients with vocal fold paresis diagnosed by LEMG at a tertiary care hospital from 2017 to 2019 were identified. Two fellowship-trained laryngologists blinded to clinical history and LEMG results reviewed laryngostroboscopic examinations and assessed for evidence of paresis using defined criteria. Inclusion criteria were adults with laryngeal asymmetry and evidence of decreased recruitment on LEMG. Exclusion criteria were children, presence of laryngeal lesions, myasthenia gravis, vocal fold paralysis, and normal laryngeal symmetry. RESULTS We identified 95 patients who were diagnosed with vocal fold paresis with LEMG who met inclusion and exclusion criteria (mean age 43.8 ± 20.4 years (18-88), 38.9% male). When comparing the laterality of the observed laryngoscopic finding with LEMG, we found that in patients who had severe true vocal fold (TVF) range of motion disturbance, the laterality of the finding matched the LEMG distribution of paresis in 12 out of 13 (92.3%) patients (P = 0.002). No other laryngoscopic findings reliably predicted laterality including corniculate and cuneiform cartilage asymmetry, pyriform sinus dilation, abnormal TVF show, petiole deviation, abnormal ventricular show, increased supraglottic area, and FVF hyperfunction of the opposite side. CONCLUSION With the exception of severe TVF range of motion disturbance, there seems to be poor validity of laryngoscopic findings in predicting the affected side in vocal fold paresis. We recommend neurophysiologic testing to confirm the clinical diagnosis of vocal fold paresis.
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Affiliation(s)
- Sungjin A Song
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts; Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Alena Santeerapharp
- Department of Otorhinolaryngology, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
| | - Ghiath Alnouri
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jin Park
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ramon A Franco
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts; Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.
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Ryu CH, Kwon TK, Kim H, Kim HS, Park IS, Woo JH, Lee SH, Lee SW, Lim JY, Kim ST, Jin SM, Choi SH. Guidelines for the Management of Unilateral Vocal Fold Paralysis From the Korean Society of Laryngology, Phoniatrics and Logopedics. Clin Exp Otorhinolaryngol 2020; 13:340-360. [PMID: 32877965 PMCID: PMC7669319 DOI: 10.21053/ceo.2020.00409] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 04/13/2020] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Chang Hwan Ryu
- Department of Otorhinolaryngology-Head Neck Surgery, National Cancer Center, Goyang, Korea
| | - Tack-Kyun Kwon
- Department of Otorhinolaryngology-Head Neck Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Heejin Kim
- Department of Otorhinolaryngology-Head Neck Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Han Su Kim
- Department of Otorhinolaryngology-Head Neck Surgery, Ewha Womans University College of Medcine, Seoul, Korea
| | - Il-Seok Park
- Department of Otorhinolaryngology-Head Neck Surgery, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Joo Hyun Woo
- Department of Otorhinolaryngology-Head Neck Surgery, Gachon University College of Medicine, Incheon, Korea
| | - Sang-Hyuk Lee
- Department of Otorhinolaryngology-Head Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Won Lee
- Department of Otorhinolaryngology-Head Neck Surgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jae-Yol Lim
- Department of Otorhinolaryngology-Head Neck Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seong-Tae Kim
- Department of Speech-Language Pathology, Dongshin University, Naju, Korea
| | - Sung-Min Jin
- Department of Otorhinolaryngology-Head Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Ho Choi
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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17
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Balouch B, Alnouri G, Vontela S, Tipparaju P, Sataloff RT. Laryngology Education in Otolaryngology Residency Programs - A Pilot Study. J Voice 2020; 36:538-541. [PMID: 32854998 DOI: 10.1016/j.jvoice.2020.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/25/2022]
Abstract
Laryngology is a relatively new subspecialty, and experience and training vary among residency programs. Graduated residents are expected to have training adequate to manage common laryngeal disorders, but the current adequacy of laryngology training is not known. OBJECTIVES To evaluate resident exposure to laryngology during otolaryngology residency. METHODS An anonymous, web-based, multiple choice, electronic questionnaire was sent to all 125 accredited otolaryngology training programs in the United States to distribute to otolaryngology senior residents (postgraduate year [PGY]-4, PGY-5). RESULTS Sixty-four residents (33 PGY-4 and 31 PGY-5) responded to the survey. 85.9% had had training in strobovideolaryngoscopy. Only 7.8% of residents had had training in performing or interpreting objective voice measurements, and 26.6% had had training in performing or interpreting laryngeal electromyography. 42.2% of residents had participated in a laryngeal surgical laboratory. Only 19.4% of residents had attended a national laryngology meeting during the preceding 12 months. 92.2% of residents reported that their program had a laryngologist attending, 95.3% had a speech-language pathologist in their department, and 21.9% had a laryngology fellow. 87.5% of residents reported that they do not have to transfer any laryngeal cases to another facility. Exposure to microdirect laryngoscopy, vocal fold mass excision with microflap technique, type I thyroplasty, and subglottic stenosis repair was (100%, 92.2%, 84.4%, and 96.9%, respectively). 54.7% of residents were exposed to arytenoidectomy, and 14.1% of residents were exposed to reduction of arytenoid dislocation/subluxation. 45.3% of residents reported that they had an interest in music, 25% had an interest in singing, 14.1% had an interest in acting. CONCLUSIONS More comprehensive laryngeal education could be achieved during otolaryngology residency by increasing exposure to objective voice measurements, laryngeal electromyography, and laryngeal surgery, especially arytenoid procedures including dislocation/subluxation reduction and arytenoidectomy.
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Affiliation(s)
- Bailey Balouch
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ghiath Alnouri
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Swetha Vontela
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | | | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania; Lankenau Institute for Medical Research, Wynnewood, Pennsylvania.
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18
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Liu AQ, Singer J, Lee T, Hu A. Laryngeal Electromyography-Guided Hyaluronic Acid Vocal Fold Injections for Glottic Insufficiency. Ann Otol Rhinol Laryngol 2020; 129:1063-1070. [PMID: 32484033 DOI: 10.1177/0003489420931556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To assess voice outcomes using the novel technique of in-office laryngeal electromyography-guided vocal fold injections (LEVFI) with hyaluronic acid to treat glottal insufficiency. Secondary objectives included determining the complication/completion rates and if any factors were associated with improved voice outcomes. METHODS Retrospective review of patients who received their first LEVFI from August 2017 to December 2018. Three- and six-month voice outcomes were assessed. Outcomes included voice handicap index-10 (VHI-10), maximum phonation time (MPT), perceptual analysis of voice (GRBAS), fundamental frequency, and stroboscopy. RESULTS Of the 121 eligible patients (55.4% male, age 63.7 years), 94 (77.7%) had complete 3-month data and 59 (48.8%) had complete 6-month data. VHI-10 was significantly improved from 25.7 ± 7.5 to 20.9 ± 10.9 at 3 months (P < .001) and to 19.1 ± 11.5 at 6 months (P < .001). MPT improved from 6.2 ± 5.4 seconds to 9.4 ± 7.1 seconds at 3 months (P < .001) and to 11.3 ± 8.2 seconds at 6 months (P < .001). GRBAS was improved in 74.8% of patients ([65.2, 82.8] 95% CI) at 3 months and 80.8% ([69.9, 89.1]) 95% CI) at 6 months. Stroboscopy showed a glottic gap improvement in 74.8% of patients ([65.8, 82.4] 95% CI) at 3 months and in 80.3% ([65.9, 88.5] 95% CI) at 6 months. Fundamental frequency was unchanged, as expected. Multivariate analysis reported that no factors were associated with better voice outcomes. Overall, 177/181 (97.8%) injections were completed. There were no complications. CONCLUSION In-office LEVFI is an effective, novel technique to treat glottic insufficiency with improved voice outcomes, high completion rate, and no significant complications.
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Affiliation(s)
- Alice Q Liu
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Terry Lee
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Amanda Hu
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada
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Frosolini A, Marioni G, Maiolino L, de Filippis C, Lovato A. Current management of arytenoid sub-luxation and dislocation. Eur Arch Otorhinolaryngol 2020; 277:2977-2986. [PMID: 32447498 DOI: 10.1007/s00405-020-06042-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To review the current management of arytenoid subluxation/dislocation (AS/AD) focusing on diagnostic, therapeutic, and prognostic controversies. METHODS The international literature of the last 20 years has been considered. After the application of inclusion criteria, 20 studies were selected (471 AS/AD cases in total). RESULTS All the included investigations were retrospective case series. AS/AD was often iatrogenic occurring at least in 0.01% of patients undergone endo-tracheal intubation. The most common symptom was persistent hoarseness. The diagnosis was made by video-laryngoscopy and neck computed tomography in most reports, while some used also laryngeal electromyography. Laryngeal electromyography was fundamental to rule out unilateral vocal fold paralysis, the main differential diagnosis. The surgical relocation of AS/AD under general or local anesthesia was achieved in about 80% of patients. CONCLUSION AS/AD is a mechanical disorder of the larynx that can be successfully treated if promptly diagnosed. Clinical trials and multi-centric studies are necessary to set management guidelines.
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Affiliation(s)
- Andrea Frosolini
- Audiology Unit at Treviso Hospital, Department of Neuroscience DNS, University of Padova, Piazzale Ospedale 1, 31100, Treviso, Italy
| | - Gino Marioni
- Otolaryngology Unit, Department of Neuroscience DNS, University of Padova, Padova, Italy
| | - Luigi Maiolino
- ENT Section, Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Catania, Italy
| | - Cosimo de Filippis
- Audiology Unit at Treviso Hospital, Department of Neuroscience DNS, University of Padova, Piazzale Ospedale 1, 31100, Treviso, Italy
| | - Andrea Lovato
- Audiology Unit at Treviso Hospital, Department of Neuroscience DNS, University of Padova, Piazzale Ospedale 1, 31100, Treviso, Italy.
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20
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Valentino WL, Park J, Alnouri G, Gracely EJ, Tami A, Vance D, Palmer J, Sataloff RT. Diagnostic Value of Acoustic and Aerodynamic Measurements in Vocal Fold Movement Disorders and their Correlation with Laryngeal Electromyography and Voice Handicap Index. J Voice 2019; 35:497.e1-497.e4. [PMID: 31757586 DOI: 10.1016/j.jvoice.2019.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 10/12/2019] [Accepted: 10/14/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Investigate the relationships between the Voice Handicap Index, laryngeal electromyography, and objective acoustic voice testing in order to determine the utility of these measures in the management of vocal fold movement disorders. METHODS A retrospective review of patients who had completed a Voice Handicap Index-10 (VHI-10) questionnaire, laryngeal electromyography (LEMG), and objective acoustic measurements (including jitter, relative average perturbation, shimmer, noise-to-harmonic ratio, and standard deviation of fundamental frequency). All three tests had been completed within 30 days of the initial evaluation. All patients' results for acoustic measures were recorded as standard deviations from the norm. LEMG results were converted to grade of paresis (mild, moderate, severe) based on the muscle with the lowest recruitment. Spearman correlation coefficients were calculated to determine the relationship between these three parameters. RESULTS A total of 313 subjects were included in the analysis. VHI-10, LEMG (grade of paresis), and objective acoustic measures were, at best, weakly correlated. VHI-10 was better correlated than LEMG to each acoustic parameter including the average acoustic scores; however, the highest correlation observed only reached ρ = 0.349 (P < 0.001). The acoustic variables that correlated best with VHI-10 and LEMG were the standard deviation of the fundamental frequency (ρ = 0.349, P < 0.001) and shimmer (ρ = 0.207, P < 0.001), respectively. CONCLUSION This study demonstrates that these measures are, at best, weakly associated. VHI-10 correlated better than LEMG (grade of paresis) to each acoustic voice analysis parameter. However, the maximum correlation coefficient observed was 0.349. Therefore, VHI-10 scores and objective voice acoustic measurements are not useful for predicting the severity of vocal fold movement disorders. Moreover, a given severity of paresis can have different effects on voice handicap and acoustic output in different individuals.
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Affiliation(s)
- William L Valentino
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Jin Park
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ghiath Alnouri
- Department of Otolaryngology - Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Edward J Gracely
- Epidemiology and Biostatistics, Dornsife School of Public Health - Drexel University, Philadelphia, Pennsylvania
| | - Abigail Tami
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Dylan Vance
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jesse Palmer
- Philadelphia Ear, Nose, and Throat Associates, Philadelphia, Pennsylvania
| | - Robert T Sataloff
- Department of Otolaryngology - Head and Neck Surgery, Senior Associate Dean for Clinical Academic Specialties, Drexel University College of Medicine, Philadelphia, Pennsylvania
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21
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Vocal Fold Paresis: Incidence, and the Relationship between Voice Handicap Index and Laryngeal EMG Findings. J Voice 2019; 33:940-944. [DOI: 10.1016/j.jvoice.2018.05.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 05/18/2018] [Indexed: 11/19/2022]
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22
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Korn GP, Azevedo RR, Monteiro JC, Pinheiro DS, Park SW, Biase NGD. Difficulty producing high-pitched sounds in singing: correlations with laryngostroboscopy and electromyographic findings. Braz J Otorhinolaryngol 2019; 86:669-675. [PMID: 31164276 PMCID: PMC9422624 DOI: 10.1016/j.bjorl.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/22/2019] [Accepted: 04/13/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Difficulties or limitations in producing high-pitched sounds while singing may be due to the vocal technique used or organic factor. The observation of such difficulty or limitation by singing teachers is one of the main reasons affected individuals are referred to otolaryngologists. OBJECTIVE To evaluate the laryngostroboscopic and electromyographic changes in the cricothyroid muscles of singers with difficulties or limitations producing high-pitched sounds. METHODS This is a cross-sectional study. Ten singers with difficulty producing high-pitched sounds underwent voice, laryngostroboscopic, and electromyographic evaluations. RESULTS None of the evaluated singers presented signs of impairment of the superior laryngeal nerve on laryngostroboscopy. The electromyographic findings for the cricothyroid muscle were normal for all singers. Six singers presented vocal fold lesions, seven had signs suggestive of laryngopharyngeal reflux, and two presented vascular changes. CONCLUSION No signs suggestive of superior laryngeal nerve paresis or paralysis were observed on laryngostroboscopy and electromyography of the cricothyroid muscle in singers with difficulties or limitations producing high-pitched sounds. The presence of vocal fold lesions should be investigated in this population.
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Affiliation(s)
- Gustavo Polacow Korn
- Universidade Federal São Paulo, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil.
| | - Renata Rangel Azevedo
- Universidade Federal São Paulo, Departamento de Fonoaudiologia, São Paulo, SP, Brazil
| | - Juliana Ceglio Monteiro
- Universidade Federal São Paulo, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil
| | | | - Sung Woo Park
- Universidade Federal São Paulo, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil
| | - Noemi Grigoletto de Biase
- Universidade Federal São Paulo, Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, São Paulo, SP, Brazil
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Shah R, DeFatta RA, Sataloff RT. Office Assessment of Vocal Fold Hypomobility. EAR, NOSE & THROAT JOURNAL 2019. [DOI: 10.1177/0145561313092010-1105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ronak Shah
- Department of Otolaryngology-Head and Neck Surgery,
Drexel University College of Medicine, Philadelphia
| | - Rima A. DeFatta
- Department of Otolaryngology-Head and Neck Surgery,
Drexel University College of Medicine, Philadelphia
| | - Robert T. Sataloff
- Department of Otolaryngology-Head and Neck Surgery,
Drexel University College of Medicine, Philadelphia
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Halum SL, Bijangi-Vishehsaraei K, Saadatzadeh MR, McRae BR. Differences in Laryngeal Neurotrophic Factor Gene Expression after Recurrent Laryngeal Nerve and Vagus Nerve Injuries. Ann Otol Rhinol Laryngol 2019. [DOI: 10.1177/000348941312201009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stacey L. Halum
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - M. Reza Saadatzadeh
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Bryan R. McRae
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Klinge K, Guntinas-Lichius O, Naumann A, Mueller AH. Ultrasonography-guided electromagnetic needle tracking in laryngeal electromyography. Eur Arch Otorhinolaryngol 2019; 276:1109-1115. [DOI: 10.1007/s00405-019-05360-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/22/2019] [Indexed: 12/01/2022]
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Bracken DJ, Ornelas G, Coleman TP, Weissbrod PA. High-density surface electromyography: A visualization method of laryngeal muscle activity. Laryngoscope 2019; 129:2347-2353. [PMID: 30663053 DOI: 10.1002/lary.27784] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 11/07/2018] [Accepted: 12/10/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Laryngeal muscle activation is a complex and dynamic process. Current evaluation methods include needle and surface electromyography (sEMG). Limitations of needle electromyography include patient discomfort, interpretive complexity, and limited duration of recording. sEMG demonstrates interpretive challenges given loss of spatial selectivity. Application of high-density sEMG (HD sEMG) arrays were evaluated for potential to compensate for spatial selectivity loss while retaining benefits of noninvasive monitoring. STUDY DESIGN Basic science. METHODS Ten adults performed phonatory tasks while a 20-channel array recorded spatiotemporal data of the anterior neck. Data were processed to provide average spectral power of each electrode. Comparison was made between rest, low-, and high-pitch phonation. Two-dimensional (2D) spectral energy maps were created to evaluate use in gross identification of muscle location. RESULTS Three phonatory tasks yielded spectral power measures across the HD sEMG array. Each electrode within the array demonstrated unique power values across all subjects (P < .001). Comparison of each electrode to itself across phonatory tasks yielded differences in all subjects during rest versus low versus high, rest versus low, and rest versus high and in 9/10 subjects (P < .001) for low versus high phonation. Symmetry of HD sEMG signal was noted. Review of 2D coronal energy maps allowed for gross identification of cricothyroid muscle amidst anterior strap musculature. CONCLUSIONS HD sEMG can be used to identify differences in anterior neck muscle activity between rest, low-, and high-pitch phonation. HD sEMG of the anterior neck holds potential to enhance diagnostic and therapeutic monitoring for pathologies of laryngeal function. LEVEL OF EVIDENCE NA Laryngoscope, 129:2347-2353, 2019.
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Affiliation(s)
- David J Bracken
- Department of Surgery-Division of Otolaryngology, University of California, San Diego, California, U.S.A
| | - Gladys Ornelas
- Department of Bioengineering, University of California, San Diego, La Jolla, California, U.S.A
| | - Todd P Coleman
- Department of Bioengineering, University of California, San Diego, La Jolla, California, U.S.A
| | - Philip A Weissbrod
- Department of Surgery-Division of Otolaryngology, University of California, San Diego, California, U.S.A
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Vocal fold paresis: Medical specialists' opinions on standard diagnostics and laryngeal findings. Eur Arch Otorhinolaryngol 2018; 275:2535-2540. [PMID: 30141109 DOI: 10.1007/s00405-018-5102-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE There is still no clear consensus on the diagnostic value of specific laryngeal findings in patients with suspected vocal fold paresis (VFP). The aim of the study was to establish expert opinion on criteria for the diagnosis of VFP in Europe. METHODS A cross-sectional survey using the questionnaire introduced by Wu and Sulica for US American experts was addressed to laryngeal experts in Germany, Austria, and Switzerland and in a second survey wave to members of the European Laryngological Society. RESULTS 100 respondents returned survey 1 (response rate 47.2%). 26% worked at a university department. 28% regularly used laryngeal electromyography (LEMG). A pathologic test results in LEMG was considered to have the strongest positive predictive value for VFP (79 ± 23%), followed by a decreased vocal fold abduction (70 ± 29%), decreased vocal fold adduction (61 ± 34%), and atrophy of the hemilarynx (61 ± 31%). The multivariate analysis showed the predictive value of LEMG was estimated lower by respondents from non-university hospital (β = - 16.33; confidence interval (CI) = - 25.63 to - 7.02; p = 0.001) and higher in hospitals with higher frequency of VFP patients per months (β = 1.57; CI = - 0.98 to 2.16; p < 0.0001). 30 ELS members returned survey 2 (response rate, 8.4%). Their answers were not significantly different to survey 1. CONCLUSIONS The laryngology experts in Europe rely on LEMG for diagnosis of VFP like the US American experts, but paradoxically only a minority uses LEMG frequently. Next to LEMG, motion abnormities were considered to have the best predictive value for the diagnosis of VFP.
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O'Connell Ferster AP, Hu A. Perceptions of pain of laryngeal electromyography. Laryngoscope 2017; 128:896-900. [DOI: 10.1002/lary.26860] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 06/21/2017] [Accepted: 07/24/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Ashley P. O'Connell Ferster
- Department of Surgery, Division of Otolaryngology-Head & Neck Surgery; Penn State Health: Milton S. Hershey Medical Center; Hershey
| | - Amanda Hu
- Department of Otolaryngology-Head & Neck Surgery; Drexel University College of Medicine; Philadelphia Pennsylvania U.S.A
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Maamary JA, Cole I, Darveniza P, Pemberton C, Brake HM, Tisch S. Relationship Between Laryngeal Electromyography and Video Laryngostroboscopy in Vocal Fold Paralysis. J Voice 2017; 31:638-642. [DOI: 10.1016/j.jvoice.2017.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 02/06/2017] [Indexed: 11/17/2022]
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Gotxi-Erezuma I, Ortega-Galán M, Laso-Elguezabal A, Prieto Puga G, Bullido-Alonso C, García-Gutiérrez S, Anton-Ladislao A, Moreno-Alonso E. Electromyography-Guided Hyaluronic Acid Injection Laryngoplasty in Early Stage of Unilateral Vocal Fold Paralysis. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2017. [DOI: 10.1016/j.otoeng.2017.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Vocal fold paresis – a debilitating and underdiagnosed condition. The Journal of Laryngology & Otology 2017; 131:S48-S52. [DOI: 10.1017/s0022215117000810] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectives:To review the clinical signs of vocal fold paresis on laryngeal videostroboscopy, to quantify its impact on patients’ quality of life and to confirm the benefit of laryngeal electromyography in its diagnosis.Methods:Twenty-nine vocal fold paresis patients were referred for laryngeal electromyography. Voice Handicap Index 10 results were compared to 43 patients diagnosed with vocal fold paralysis. Laryngeal videostroboscopy analysis was conducted to determine side of paresis.Results:Blinded laryngeal electromyography confirmed vocal fold paresis in 92.6 per cent of cases, with vocal fold lag being the most common diagnostic sign. The laryngology team accurately predicted side of paresis in 76 per cent of cases. Total Voice Handicap Index 10 responses were not significantly different between vocal fold paralysis and vocal fold paresis groups (26.08 ± 0.21 and 22.93 ± 0.17, respectively).Conclusion:Vocal fold paresis has a significant impact on quality of life. This study shows that laryngeal electromyography is an important diagnostic tool. Patients with persisting dysphonia and apparently normal vocal fold movement, who fail to respond to appropriate speech therapy, should be investigated for a diagnosis of vocal fold paresis.
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Estes C, Sadoughi B, Mauer E, Christos P, Sulica L. Laryngoscopic and stroboscopic signs in the diagnosis of vocal fold paresis. Laryngoscope 2017; 127:2100-2105. [DOI: 10.1002/lary.26570] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 01/20/2017] [Accepted: 02/13/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Christine Estes
- Department of Otolaryngology-Head and Neck Surgery; Sean Parker Institute for the Voice; New York New York U.S.A
| | - Babak Sadoughi
- Department of Otolaryngology-Head and Neck Surgery; Sean Parker Institute for the Voice; New York New York U.S.A
| | - Elizabeth Mauer
- Department of Biostatistics and Epidemiology; Weill Cornell Medical College; New York New York U.S.A
| | - Paul Christos
- Department of Biostatistics and Epidemiology; Weill Cornell Medical College; New York New York U.S.A
| | - Lucian Sulica
- Department of Otolaryngology-Head and Neck Surgery; Sean Parker Institute for the Voice; New York New York U.S.A
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Electromyography-guided hyaluronic acid injection laryngoplasty in early stage of unilateral vocal fold paralysis. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2017; 68:274-283. [PMID: 28238367 DOI: 10.1016/j.otorri.2016.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 11/23/2016] [Accepted: 12/06/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION AND OBJECTIVE To assess the effectiveness of electromyography-guided hyaluronic acid injection laryngoplasty in the early stage of unilateral vocal fold paralysis in terms of patient recovery from dysphonia and quality of life. METHODS Between January and December 2014, 28 patients with unilateral vocal fold paralysis underwent electromyography and injection of hyaluronic acid in the thyroarytenoid muscle. We compared the voice handicap index, grade, roughness, breathiness, asthenia, strain scale (GRBAS), videostroboscopic parameters and maximum phonation time assessed before, 15 days and 6 months after the intervention, using the non-parametric Wilcoxon rank test. RESULTS Out of the 28 patients, 1 had a haematoma in the injected vocal fold (3.57%) and 6 required second injections. The maximum phonation time of the vowel /e/ increased from 6.07 to 12.14 sec. (15 days post-intervention) and subsequently 12.75 (6 months post-intervention). There was also a significant improvement in the grade, roughness, breathiness, asthenia, strain scale in parameters G, B and A both 15 days and 6 months after the intervention. The voice handicap index score decreased from 58.29 to 37.63 (15 days post-intervention) and 29.64 (6 months post-intervention). CONCLUSIONS Electromyography-guided hyaluronic injection laryngoplasty in unilateral vocal fold paralysis enables, in the same intervention, neuromuscular assessment and temporary treatment of glottic insufficiency with a low risk of complications and improvement in patient's quality of life. This may reduce the need for subsequent treatments, but further research is required to confirm these findings.
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Keseroglu K, Bayir O, Umay EK, Saylam G, Tatar EC, Ozdek A, Korkmaz MH. Laryngeal electromyographic changes in postthyroidectomy patients with normal vocal cord mobility. Eur Arch Otorhinolaryngol 2017; 274:1925-1931. [PMID: 28132134 DOI: 10.1007/s00405-016-4442-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 12/22/2016] [Indexed: 11/27/2022]
Abstract
Thyroidectomy has been used for the treatment of thyroid disease for more than 100 years. In spite of the advancement of surgical techniques, there is still a risk of laryngeal nerve injury. The risk of partial or complete injury still depends on some surgical and disease-related factors. The aim of this study is to show the partial injury and to establish these risk factors via laryngeal electromyographic analysis (LEMG) in postthyroidectomy patients with normal vocal cord motion and mucosal anatomy. Patients who had undergone thyroid surgery were enrolled in this prospective study. LEMG analysis was performed to all patients with normal vocal cord mobility preoperatively and was repeated after the first and the third months of surgery. Thyroarytenoid (TA) and cricothyroid (CT) muscles were used to evaluate recurrent and external branch of superior laryngeal nerves, respectively. Four of the 32 patients had mild-to-moderate degrees of partial LEMG changes during preoperative LEMG analysis of TA and CT muscles on each side. After 3 months of surgery, there was a statistically significant worsening of LEMG findings in the right and left external branches of superior and left recurrent laryngeal nerves. Disease and surgery-related risk factors were analyzed. However, there was no significant relationship on the progression of LEMG findings according to these parameters. This is the first prospective study which supports the risk of progression of LEMG changes in patients with normal laryngoscopic examination after thyroid surgery. No reliable significant risk factor was found influencing the LEMG progression.
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Affiliation(s)
- Kemal Keseroglu
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey.
| | - Omer Bayir
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey
| | - Ebru Karaca Umay
- Physical Medicine and Rehabilitation Department, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Guleser Saylam
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey
| | - Emel Cadalli Tatar
- Otolaryngology Department, Diskapi Yildirim Beyazit Training and Research Hospital, 1426 Street No: 28/11 Cukurambar, 06510, Ankara, Turkey
| | | | - Mehmet Hakan Korkmaz
- Faculty of Medicine Otolaryngology Department, Yildirim Beyazit University, Ankara, Turkey
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Tewari A, Samy RN, Castle J, Frye TM, Habeych ME, Mohamed M. Intraoperative Neurophysiological Monitoring of the Laryngeal Nerves During Anterior Neck Surgery: A Review. Ann Otol Rhinol Laryngol 2016; 126:67-72. [PMID: 27803238 DOI: 10.1177/0003489416675354] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Contributions to the literature on intraoperative neuro monitoring (IONM) during endocrine and head and neck surgery have increased over recent years. Organizational support for neural monitoring during surgery is becoming evident and is increasingly recognized as an adjunct to visual nerve identification. A comprehensive understanding of the role of IONM for prevention of nerve injuries is critical to maximize safety during surgery of the anterior compartment of the neck. This review will explore the potential advantages of IONM to improve the outcomes among patients undergoing anterior neck surgery.
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Affiliation(s)
- Anurag Tewari
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Ravi N Samy
- Department of Otolaryngology, University of Cincinnati, Cincinnati, Ohio, USA
| | | | | | - Miguel E Habeych
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Mahmoud Mohamed
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Ohio, USA
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Diagnostic and prognostic contribution of laryngeal electromyography in unilateral vocal-fold immobility in adults. Eur Ann Otorhinolaryngol Head Neck Dis 2016; 134:13-18. [PMID: 27720373 DOI: 10.1016/j.anorl.2016.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To study the diagnostic and prognostic contribution of laryngeal electromyography in unilateral vocal-fold immobility in adults. MATERIAL AND METHODS A retrospective study included patients with unilateral vocal-fold immobility undergoing laryngeal electromyography between 2007 and 2015. Neurogenic, normal or myogenic findings were compared to the clinical aspect. Prognosis for recovery was assessed from motor unit potentials on laryngeal electromyography, and compared to subsequent progress on laryngoscopy. RESULTS Sixty-three patients (mean age, 59 years) were initially included; 2 were subsequently excluded from analysis. Mean time from onset of immobility to laryngeal electromyography was 7 months. 85% of the 61 patients showed neurogenic findings, indicating neural lesion; 13% showed normal electromyography, indicating cricoarytenoid joint ankylosis; and 1 patient showed a myogenic pattern. Neurogenic cases were usually secondary to cervical surgery. Thirty-eight patients were followed up. In total, 75% of patients showing reinnervation potentials recovered. The positive predictive value of laryngeal electromyography was 69.2%. CONCLUSION Laryngeal electromyography is effective in specifying the origin of unilateral vocal-fold immobility in adults. It also has a prognostic role, lack of reinnervation potentials being a possible indication for early medialization surgery.
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Woo P, Isseroff TF, Parasher A, Richards A, Sivak M. Laryngeal Electromyographic findings in patients with vocal fold motion asymmetry. Laryngoscope 2016; 126:E273-7. [DOI: 10.1002/lary.26059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 03/23/2016] [Accepted: 04/04/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Peak Woo
- Department of Otolaryngology; Mount Sinai Medical Center; New York New York U.S.A
| | - Tova F. Isseroff
- Department of Otolaryngology; Mount Sinai Medical Center; New York New York U.S.A
| | - Arjun Parasher
- Department of Otolaryngology; Mount Sinai Medical Center; New York New York U.S.A
| | - Amanda Richards
- Department of Otolaryngology; Mount Sinai Medical Center; New York New York U.S.A
| | - Mark Sivak
- Department of Neurology; Mount Sinai Medical Center; New York New York U.S.A
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Park HS, Jung SY, Yoo JH, Park HJ, Lee CH, Kim HS, Chung SM. Clinical Usefulness of Ultrasonography-Guided Laryngeal Electromyography. J Voice 2015; 30:100-3. [PMID: 26602419 DOI: 10.1016/j.jvoice.2015.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/18/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate the proper approach and technical method of ultrasonography-guided laryngeal electromyography (US-guided LEMG). STUDY DESIGN This is a prospective study. METHODS Twenty patients who underwent US-guided LEMG were enrolled. US-guided LEMG was cooperatively performed by one otolaryngologist, one neurologist, and one radiologist. The location of the needle electrode was confirmed with US after electrode insertion into the laryngeal intrinsic muscle. The US transducer was applied on the neck by a transverse/midline and transverse/oblique approach to identify the cricothyroid (CT), thyroarytenoid (TA) muscles, and the location of the needle electrode. RESULTS CT muscles were easily identified on US in all 20 patients. TA muscles were identified in 17 patients (85%). The transverse/oblique approach was helpful to detect TA muscle in case of calcified thyroid cartilage or anatomic variation. CONCLUSIONS US-guided LEMG, which enables the exact insertion of the needle electrode, improves the reliability of examination and is helpful in early detection and to prevent complications.
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Affiliation(s)
- Hae Sang Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Chuncheon Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon, Korea
| | - Soo Yeon Jung
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Jeong Hyun Yoo
- Department of Radiology, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Hyung Jun Park
- Department of Neurology, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Cha Hee Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Han Su Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Sung Min Chung
- Department of Otorhinolaryngology-Head and Neck Surgery, School of Medicine, Ewha Womans University, Seoul, Korea.
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Tatar EÇ, Öcal B, Korkmaz H, Ünlü E, Sürenoğlu ÜA, Saylam G, Özdek A. Postviral Vagal Neuropathy: What Is the Role of Laryngeal Electromyography in Improving Diagnostic Accuracy? J Voice 2015; 29:595-9. [DOI: 10.1016/j.jvoice.2014.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 10/14/2014] [Indexed: 11/27/2022]
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Crespo AN, Kimaid PA, Machado Júnior AJ, Wolf AE. Laryngeal Electromyography: Are the Results Reproducible? J Voice 2015; 29:498-500. [DOI: 10.1016/j.jvoice.2014.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 09/08/2014] [Indexed: 10/23/2022]
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J. Kim S, G. Lee D, Kwon JY. Development of a nerve conduction technique for the recurrent laryngeal nerve. Laryngoscope 2014; 124:2779-84. [DOI: 10.1002/lary.24831] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 05/22/2014] [Accepted: 06/24/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Sang J. Kim
- Department of Physical and Rehabilitation Medicine; Samsung Medical Center; Seoul South Korea
| | - Dae G. Lee
- Department of Physical and Rehabilitation Medicine; Samsung Medical Center; Seoul South Korea
| | - Jeong-Yi Kwon
- Department of Physical and Rehabilitation Medicine; Samsung Medical Center; Seoul South Korea
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The effect of patient age on the success of laryngeal reinnervation. Eur Arch Otorhinolaryngol 2014; 271:3241-7. [DOI: 10.1007/s00405-014-3091-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
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Chen X, Wan P, Yu Y, Li M, Xu Y, Huang P, Huang Z. Types and timing of therapy for vocal fold paresis/paralysis after thyroidectomy: a systematic review and meta-analysis. J Voice 2014; 28:799-808. [PMID: 24739443 DOI: 10.1016/j.jvoice.2014.02.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 02/10/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To perform a systematic literature review to evaluate the type and timing of therapy for vocal fold paresis/paralysis after thyroidectomy and develop a primary decision-making pathway. STUDY DESIGN Meta-analysis. METHODS Four databases and one journal were searched using the key words of "thyroidectomy," "vocal cord paresis/paralysis," and "therapy." Study quality was evaluated using the Cochrane Collaboration's risk of bias tools. Data regarding type and timing of therapy were extracted from 39 articles. Odds ratios (ORs), relative risk (RR), 95% confidence interval, and heterogeneity were recorded. Logistic regression analysis was performed to determine the relationships between timing and OR/RR. RESULTS Among the 13 studies investigating unilateral paresis/paralysis, five focused on early therapy (0-6 months). In these studies, the OR for clinical heterogeneity was significantly higher after neurolysis than after injection laryngoplasty and voice training (Q = 17.002, I(2) = 78%, P = 0.000), and the RR for heterogeneity was significantly higher after injection laryngoplasty at ≥12 months than <12 months (Q = 9.984, I(2) = 89.9%, P = 0.002). In the 26 studies that investigated bilateral paresis/paralysis, the OR for heterogeneity was significantly higher for bilateral posterior cordectomy than for endolaryngeal laterofixation (Q = 3.510, I(2) = 71.5%, P = 0.061) and laser arytenoidectomy with posterior cordectomy (Q = 2.90, I(2) = 65.6%, P = 0.088). CONCLUSIONS For unilateral vocal fold paresis/paralysis after thyroidectomy, we recommend absorbable mass injection laryngoplasty, voice training, and neurolysis during the first 12 months but laryngeal reinnervation after 12 months. For bilateral vocal fold paresis/paralysis, we recommend early laterofixation and combined laser arytenoidectomy with posterior cordectomy after 12 months.
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Affiliation(s)
- Xuhui Chen
- Department of Ear, Nose and Throat, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ping Wan
- Department of Voice and Swallowing Rehabilitation, Rehabilitation School, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
| | - Yabin Yu
- Department of Ear, Nose and Throat, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ming Li
- Department of Ear, Nose and Throat, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yanyan Xu
- Department of Voice and Swallowing Rehabilitation, Rehabilitation School, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ping Huang
- Department of Ear, Nose and Throat, Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zaoming Huang
- Department of Voice Science, Key National Laboratory of Speech and Hearing Science, East China Normal University, Shanghai, China
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Croake DJ, Stemple JC, Uhl T, Archer S, Andreatta RD. Reliability of clinical office-based laryngeal electromyography in vocally healthy adults. Ann Otol Rhinol Laryngol 2014; 123:271-8. [PMID: 24671483 DOI: 10.1177/0003489414525022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study aimed to conduct a 3-session reliability assessment of the laryngeal electromyography (LEMG) signal in healthy participants during intensity controlled vocalization tasks. We hypothesized that vocal intensity level and testing session would affect LEMG measures. METHODS This prospective study used a 2-factor repeated measures design. Seven participants underwent bipolar needle LEMG of the right thyroarytenoid muscle. Data were collected over 3 testing sessions using vocalization tasks performed with visually guided intensity feedback targets (65 and 75 dB SPL). Root mean square amplitudes in microvolts were analyzed for within-session and between-session reliability. RESULTS The main effect for intensity was found to approach significance (F = 5.71, P = .054). However, intraclass correlation coefficients (ICCs) using a 2-factor mixed random effect model indicated poor to fair signal reliability between testing sessions (ICC = 0.56 at 65 dB, 0.40 at 70 dB). Intraclass correlation coefficients for within-session data indicated excellent reliability for all testing conditions (0.84-0.98). CONCLUSION Using a quantitative analysis protocol to inform an essentially qualitative technique, our results indicated that there was generally poor to fair reliability in the LEMG signal over testing sessions. Vocal intensity was an important variable that affected LEMG signal reliability. Standardization of LEMG protocols using vocal control parameters and quantitative analyses may help improve LEMG reliability in clinical settings.
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Affiliation(s)
- Daniel J Croake
- College of Health Sciences, University of Kentucky, Lexington, Kentucky, USA
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Use of Ultrasonography to Locate Laryngeal Structures for Laryngeal Electromyography. PM R 2013; 6:522-7. [DOI: 10.1016/j.pmrj.2013.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 11/11/2013] [Accepted: 11/14/2013] [Indexed: 11/20/2022]
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Chandrasekhar SS, Randolph GW, Seidman MD, Rosenfeld RM, Angelos P, Barkmeier-Kraemer J, Benninger MS, Blumin JH, Dennis G, Hanks J, Haymart MR, Kloos RT, Seals B, Schreibstein JM, Thomas MA, Waddington C, Warren B, Robertson PJ. Clinical Practice Guideline. Otolaryngol Head Neck Surg 2013; 148:S1-37. [DOI: 10.1177/0194599813487301] [Citation(s) in RCA: 289] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient’s voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period. Purpose The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well. Results The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient’s voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient’s voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient’s voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.
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Affiliation(s)
| | - Gregory W. Randolph
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Michael D. Seidman
- Department of Otolaryngology, Henry Ford Medical Center, West Bloomfield, Michigan, USA
| | - Richard M. Rosenfeld
- Department of Otolaryngology, State University of New York Downstate Medical Center, Brooklyn, New York, USA
| | - Peter Angelos
- University of Chicago Medical Center, Chicago, Illinois, USA
| | | | | | - Joel H. Blumin
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - John Hanks
- University of Virginia, School of Medicine, Charlottesville, Virginia, USA
| | - Megan R. Haymart
- Department of Internal Medicine, Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Brenda Seals
- Native American Cancer Research, Denver, Colorado, USA
| | - Jerry M. Schreibstein
- Ear, Nose and Throat Surgeons of Western New England LLC, Springfield, Massachusetts, USA
| | | | | | - Barbara Warren
- LGBT Health Services, Beth Israel Medical Center, New York, New York, USA
| | - Peter J. Robertson
- American Academy of Otolaryngology—Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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