Diagnosis Of Vocal Fold Paresis Research Articles

The Poor Validity of Asymmetric Laryngoscopic Findings in Predicting Laterality in Vocal Fold Paresis

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). Blinded, prospective video perceptual analysis study. 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. 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. 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.

A 4-year Retrospective Review of the Presence and Pattern of Ventricular Hyperadduction Following Unilateral Vocal Fold Paralysis, Paresis, and Unilateral Cordectomy

The aim of our study was to determine the presence and pattern of ventricular hyperadduction (VH) following unilateral vocal fold (VF) paralysis/paresis and that following unilateral cordectomy (UC). The authors independently reviewed charts and flexible videostroboscopic recordings of 214 patients diagnosed with unilateral VF paralysis/paresis and those who had undergone UC from 2015 to 2018. The presence and pattern of VH was noted. VH was considered to be present when the false vocal fold (FVF) obliterated 50% or more of the true vocal fold width during phonation, with or without FVF vibration. The true vocal fold width was considered to be that which was visible on abduction of the VFs. Categorical variables were presented in numbers and percentages and qualitative variables were correlated using Chi-Square test. Odds ratio with 95% Confidence Interval was calculated. In 154 patients diagnosed as unilateral VF paralysis/paresis 85 patients had a VH pattern (55.19%) with contralateral VH observed in 74 (87.05%), ipsilateral VH observed in 6 (7.05%) and bilateral VH observed in five patients (5.88 %). The total number of patients of UC was 60 with 36 of these patients developing a VH (60%). Ipsilateral VH was observed in 28 of these 36 patients (77.77%), three patients developed contralateral VH (8.33%) and five patients developed bilateral VH (13.88%). Ipsilateral ventricular hyper-adduction following unilateral cordectomy in the group of patients that develop hyperadduction is a significant finding in our study suggesting possibility of unilateral central phonatory control of the FVF. Contralateral ventricular hyper-adduction following unilateral paralysis and paresis, in the group of patients that develop hyperadduction is a significant finding in our study and this finding resonates with previously published papers. A finding of unilateral VH may serve as a possible indicator of the occasionally challenging diagnosis of vocal fold paresis. Retrospective, Observational.

Diagnosis of vocal fold paresis: current opinion and practice.

No accepted standard exists for the diagnosis of vocal fold paresis (VFP). Laryngeal specialists are surveyed to establish expert opinion on diagnostic methodology and criteria. Cross-sectional survey. Questionnaires were distributed at laryngology conferences in fall 2013. Responses were collated anonymously and subjected to cross-tabulated data analysis. Fifty-eight responses completed by posttraining physicians whose practice focused in laryngology ≥ 75% were analyzed. One (1.7%) relied principally on laryngeal electromyography, one (1.7%) on history, 10 (17%) on laryngoscopy, and 42 (72%) on strobovideolaryngoscopy for diagnosis. Only 12 (21%) performed laryngeal electromyography on > 50% of vocal fold paresis patients. Laryngeal electromyography sensitivity was considered moderate (61 ± 3.7%, σ = 28). Laryngoscopic/stroboscopic findings considered to have the strongest positive predictive value for VFP were slow/sluggish vocal fold motion (75 ± 3.0%, σ = 23), decreased adduction (67 ± 3.5%, σ = 27), decreased abduction (65 ± 3.4%, σ = 26), and decreased vocal fold tone (61 ± 3.5%, σ = 26). Asymmetric mucosal wave amplitude (52 ± 4.2%, σ = 32), asymmetric mucosal wave phase (60 ± 4.1%, σ = 31), hemilaryngeal atrophy (60 ± 4.0%, σ = 31), and asymmetric mucosal wave frequency (49 ± 4.0%, σ = 30) generated greatest disagreement. Surveyed expert laryngologists diagnose vocal fold paresis predominantly on stroboscopic examination. Gross motion abnormalities had the highest positive predictive value. Laryngeal electromyography was infrequently used to assess for vocal fold paresis.

Diagnostic Yield of Computed Tomography in Evaluation of Vocal Fold Paresis: Is It Worth It?

Objectives: (1) Determine the diagnostic yield of contrast-enhanced computed tomography (CT) in the evaluation of patients with idiopathic unilateral vocal fold paresis. (2) Determine the proportion of CTs yielding nondiagnostic incidental findings requiring further patient management. Methods: Retrospective cohort. Precision-based power calculations were performed. All patients of the 2 senior authors who underwent contrast-enhanced CT for a clinical diagnosis of vocal fold paresis from January 2004 to January 2014 were included. Demographic, history, examination, and investigation data were extracted from outpatient records and CT reports were reviewed. Patients were excluded if there was insufficient history or examination information, if there was a known neurological diagnosis, or if there was vocal fold immobility or bilateral involvement. A diagnostic CT was defined as depicting a pathological lesion along the course of the ipsilateral recurrent or superior laryngeal nerves. Incidental CT findings were defined as those unrelated to paresis and requiring further intervention. Results: A total of 128 patients were included in the study. Three out of 128 patients had a diagnostic CT equating to a diagnostic yield of 2.3% (0.49-6.7 95% confidence interval [CI]). Thirty-nine out of 128 patients, or 30.5% (22.6-39.2 95% CI) had an incidental CT finding requiring further management. Conclusions: Contrast-enhanced CT has a low yield of 2.3% in the initial evaluation of idiopathic vocal fold paresis. Conversely, CT has a high, 30.5% yield of incidental cervico-thoracic lesions. This would suggest that the routine use of CT in the evaluation of idiopathic vocal fold paresis is not warranted.

Neurosarcoidosis Affecting the Vagus Nerve

Our objective was to review patients who presented to our medical center with a diagnosis of neurosarcoidosis affecting the vagus nerve and to present symptoms, progression, treatments, and outcome. We performed a chart review of patients who presented to our medical center in the past 10 years with a diagnosis of neurosarcoidosis specifically affecting cranial nerve X. A chart review of 53 patients revealed only 4 with findings suggestive of vagal neurosarcoidosis. All were male and had a mean age of 50 years (range, 42 to 57 years) at presentation of symptoms. Two of the 4 patients presented initially with cough, 1 had recurrent syncope, and another presented with left facial pain. Vagus nerve involvement included vocal fold paresis or paralysis in all 4 patients, 2 of whom reported coughing with exposure to various odors and 2 of whom were found to have a unilateral palatal weakness. All but 1 had positive findings on magnetic resonance imaging of the head. Neurosarcoidosis involving the vagus nerve is a rare finding, but should be considered in the differential diagnosis of vocal fold paresis or paralysis.

Automatic diagnosis of vocal fold paresis by employing phonovibrogram features and machine learning methods

The clinical diagnosis of voice disorders is based on examination of the rapidly moving vocal folds during phonation (f0: 80–300 Hz) with state-of-the-art endoscopic high-speed cameras. Commonly, analysis is performed in a subjective and time-consuming manner via slow-motion video playback and exhibits low inter- and intra-rater reliability. In this study an objective method to overcome this drawback is presented being based on Phonovibrography, a novel image analysis technique. For a collective of 45 normophonic and paralytic voices the laryngeal dynamics were captured by specialized Phonovibrogram features and analyzed with different machine learning algorithms. Classification accuracies reached 93% for 2-class and 73% for 3-class discrimination. The results were validated by subjective expert ratings given the same diagnostic criteria. The automatic Phonovibrogram analysis approach exceeded the experienced raters’ classifications by 9%. The presented method holds a lot of potential for providing reliable vocal fold diagnosis support in the future.

Recommendations of the Neurolaryngology Study Group on laryngeal electromyography

The Neurolaryngology Study Group convened a multidisciplinary panel of experts in neuromuscular physiology, electromyography, physical medicine and rehabilitation, neurology, and laryngology to meet with interested members from the American Academy of Otolaryngology Head and Neck Surgery, the Neurolaryngology Subcommittee and the Neurolaryngology Study Group to address the use of laryngeal electromyography (LEMG) for electrodiagnosis of laryngeal disorders. The panel addressed the use of LEMG for: 1) diagnosis of vocal fold paresis, 2) best practice application of equipment and techniques for LEMG, 3) estimation of time of injury and prediction of recovery of neural injuries, 4) diagnosis of neuromuscular diseases of the laryngeal muscles, and, 5) differentiation between central nervous system and behaviorally based laryngeal disorders. The panel also addressed establishing standardized techniques and methods for future assessment of LEMG sensitivity, specificity and reliability for identification, assessment and prognosis of neurolaryngeal disorders. Previously an evidence-based review of the clinical utility of LEMG published in 2004 only found evidence supported that LEMG was possibly useful for guiding injections of botulinum toxin into the laryngeal muscles. An updated traditional/narrative literature review and expert opinions were used to direct discussion and format conclusions. In current clinical practice, LEMG is a qualitative and not a quantitative examination. Specific recommendations were made to standardize electrode types, muscles to be sampled, sampling techniques, and reporting requirements. Prospective studies are needed to determine the clinical utility of LEMG. Use of the standardized methods and reporting will support future studies correlating electro-diagnostic findings with voice and upper airway function.

High-Speed Imaging Used to Detect Vocal Fold Paresis: A Case Report

High-speed imaging has been used to study vocal fold vibration and has been shown to provide additional information in aid of our understanding of pathologic vocal fold vibration. This is the first case report of vocal fold paresis diagnosed by high-speed imaging. An 18-year-old girl presented with intermittent voice loss that had been present for 4 years. The patient had been seen by other otolaryngologists and had been given proton pump inhibitors without any improvement in her voice. Her voice was diplophonic. The patient was examined by rigid stroboscopy and was found to have a predominantly open phase pattern but a normal vibratory pattern. High-speed photography showed a distinct vibratory frequency for each vocal fold, suggestive of a paresis pattern. Laryngeal electromyography confirmed the diagnosis of vocal fold paresis. A computed tomographic scan of the larynx and chest showed a thymoma. After thymectomy, the patient recovered full voice function. High-speed imaging is useful for the clinical evaluation of pathologic vocal fold vibration and can detect subtle features of paralysis that may not be detected on fiberoptic endoscopy and rigid stroboscopy. The additional information from high-speed imaging helped to make the diagnosis of vocal fold paresis in this patient.

Dynamic voice assessment using flexible laryngoscopy—how I do it: a targeted problem and its solution

Flexible laryngoscopy is a staple of the otolaryngologist’s office examination. This technique is frequently used for evaluation of gross pathologies of the larynx and pharynx as well as assessment of mobility of the vocal folds. By incorporation of a specific set of phonatory and vegetative tasks, the depth and detail of information gathered using flexible laryngoscopy can be greatly enhanced. Because the patient remains in a near-physiologic position, incorporation of these tasks into the flexible laryngoscopic examination provides essential information for the diagnosis of a variety of functional and neurologic disorders of the larynx and pharynx. Videostroboscopy can be performed by using the flexible laryngoscope, potentially circumventing the need for rigid endoscopic evaluation of small vocal fold lesions. By using this technique, subtle abnormalities of vocal fold motion can be detected, thus assisting in the diagnosis of vocal fold paresis and superior laryngeal nerve palsy. Here we describe a rapid but thorough method for evaluation of neurologic and functional voice and breathing disorders using flexible laryngoscopy (Table 1).

LARYNGEAL ELECTROMYOGRAPHY: Diagnostic and Prognostic Applications

Laryngeal electromyography is a crucial diagnostic test in laryngology. Laryngeal electromyography is important for the diagnosis of vocal fold paresis and cricoarytenoid joint pathology (e.g., arytenoid dislocation). In addition, laryngeal electromyography offers prognostic information regarding potential vocal fold paralysis recovery, which can improve the management strategies for vocal fold paralysis.

Vocal fold paresis

Vocal fold paresis (VFP) is a relatively common and often overlooked condition that can be difficult to diagnose based on the laryngeal examination alone. A retrospective review of the records of 50 consecutive adult patients with VFP was performed. In each case, the diagnosis of VFP was confirmed by laryngeal electromyography. The presenting symptoms were dysphonia (100%), vocal fatigue (76%), diplophonia (40%), and odynophonia (12%), and the findings were unilateral vocal fold hypomobility (50%), unilateral bowing (36%), and bilateral bowing (22%). Laryngoplasty and/or lipoinjection was performed in 54% of the subjects, and significant vocal improvement was achieved in 85%. VFP appears to be underdiagnosed because many VFP patients have compensatory hyperkinetic disorders at presentation. Although the diagnosis of VFP may be suspected based on the patient’s symptoms and findings, the diagnostic sine qua non is laryngeal electromyography. In addition, surgical treatment for VFP appears to be safe and effective. (Otolaryngol Head Neck Surg 2000;122:537-41.)

Vocal fold paresis

Vocal fold paresis (VFP) is a relatively common and often overlooked condition that can be difficult to diagnose based on the laryngeal examination alone. A retrospective review of the records of 50 consecutive adult patients with VFP was performed. In each case, the diagnosis of VFP was confirmed by laryngeal electromyography. The presenting symptoms were dysphonia (100%), vocal fatigue (76%), diplophonia (40%), and odynophonia (12%), and the findings were unilateral vocal fold hypomobility (50%), unilateral bowing (36%), and bilateral bowing (22%). Laryngoplasty and/or lipoinjection was performed in 54% of the subjects, and significant vocal improvement was achieved in 85%. VFP appears to be underdiagnosed because many VFP patients have compensatory hyperkinetic disorders at presentation. Although the diagnosis of VFP may be suspected based on the patient's symptoms and findings, the diagnostic sine qua non is laryngeal electromyography. In addition, surgical treatment for VFP appears to be safe and effective.