Laryngeal Ultrasonography Research Articles

Vocal Cord Palsies Missed by Transcutaneous Laryngeal Ultrasound (TLUSG): Do They Experience Worse Outcomes?

Transcutaneous laryngeal ultrasound (TLUSG) is an innovative, non-invasive tool in detecting post-thyroidectomy vocal cord palsy (VCP). However, TLUSG failed to detect about 6-15% laryngoscopic examination (LE)-confirmed VCP. It is unclear whether the outcome of patients with VCP missed by TLUSG [false negative (FN)] is different from those with VCP diagnosed by TLUSG [true positive (TP)]. Therefore, this study aimed to compare the clinical outcome and prognosis between patients with FN results and TP results. Over 46months, all consecutive patients undergoing thyroidectomy or endocrine-related neck procedure were recruited. They underwent pre-operative and post-operative voice assessments on symptoms, voice-specific questionnaire [voice handicap index questionnaire (VHI-30)], TLUSG and LE. For patients with post-operative vocal cord palsy, reassessment LE would be arranged at second, fourth, sixth and twelfthmonths post-operatively until VCP recovered. In total, 1196 patients, including 74 post-thyroidectomy VCP, were recruited. For those with assessable vocal cords (VC), 58 VCP were correctly diagnosed by TLUSG (TP) and 10 VCP were missed by TLUSG (FN). Sensitivity and specificity of detecting a VCP by TLUSG were 85.3% and 94.7%, respectively. VHI-30 score was significantly increased after operation in TP group [31 (range - 6-105), p < 0.001] but not in FN group [20 (14-99), p = 0.089]. Comparing to TP group, VCP recovered earlier (69 vs. 125days, p < 0.001) and less patients suffered from permanent VCP in patients with FN results. (34.5% vs. 0.0%, p = 0.027). The VCP missed by TLUSG had a milder course of disease. Early recovery of VC function and non-permanent palsy were expected.

Functional analysis of vocal folds by transcutaneous laryngeal ultrasonography in patients undergoing thyroidectomy.

Transcutaneous laryngeal ultrasound (TCLUS) can assess Vocal folds (VF) by subjectively identifying mobility or objectively by calculating vocal fold displacement velocity (VFDV). Optimal diagnostic approach (subjective assessment, VFDV estimation or a combination of both) is unresolved; hence, we conducted this prospective study in patients undergoing thyroidectomy. Two anaesthetists performed TCLUS pre- and post-operatively for functional assessment of 200 VFs on 100 patients. Their findings were compared with pre-operative flexible laryngoscope (FL) performed by surgeons and with post-operative C-Mac video laryngoscope (C-Mac VL) by another independent anaesthetist. Correlation between FL and TCLUS findings and inter-rater agreement between TCLUS findings of both anaesthetists was analysed. Decision curve analysis (DCA) was performed to compare clinical benefit of hoarseness, subjective VF movement, VFDV, and combined assessment for detecting disabled VFs. We found good correlation between VF mobility on TCLUS and FL (Spearman's r = 0.93, P < 0.0001) as well as C-Mac VL (Spearman's r = 0.83, P < 0.0001) with excellent inter-rater agreement between both anaesthetists. DCA showed combined assessment to have marginally higher clinical benefit than other diagnostic approaches at intermediate threshold probabilities while its benefit was similar to subjective evaluation at higher threshold probabilities. Provided achievement of optimal acoustic window, TCLUS can reliably assess disabled VFs with FL reserved for their confirmation or doubtful cases. Subjective assessment of VF mobility should suffice in most cases with additional VFDV estimation reserved pre-operatively for situations with higher risk of VFs disability, and post-operatively when subjective VF assessment findings are discordant from pre-operative status.

Ultrasound-Guided Laryngeal Air Column Width Difference as a New Predictor for Postextubation Stridor in Children

To assess the efficacy of ultrasound-guided laryngeal air column width difference in predicting postextubation stridor in children. Prospective observational study. Single, tertiary care pediatric hospital. This study was carried out at PICU and surgical ICU, Tanta University Hospital on 400 ventilated children between January 2015 and May 2017. Patients who received mechanical ventilation and met criteria for a weaning trial were included. Laryngeal ultrasound and cuff leak test. Ultrasound-guided laryngeal air column width and cuff leak test were measured before extubation. Laryngeal air column width is the width of air between the vocal cords seen by laryngeal ultrasonography. Laryngeal air column width difference is the width difference of air column passed through vocal cords with the balloon cuff inflated and deflated. Three-hundred fifty six patients (89%) had no postextubation stridor, whereas 44 patients (11%) developed postextubation stridor. Postextubation stridor was associated with younger age, less weight, female gender, prolonged duration of intubation, and ICU stay (p < 0.05). Both laryngeal air column width difference and cuff leak test showed significant decrease (p < 0.05) in patients with postextubation stridor in comparison with no postextubation stridor patients. Receiver operating characteristics curve analysis showed that laryngeal air column width difference at cutoff point of less than 0.8 mm gave a sensitivity of 93%, specificity of 86%, and accuracy of 91%, whereas cuff leak test at less than 11% yielded a sensitivity of (61%), specificity of (53%), and accuracy of (59%) for predicting postextubation stridor. Laryngeal air column width difference measurement may serve as a simple reliable noninvasive method for predicting postextubation stridor in children.

Laryngeal ultrasound for the diagnosis of laryngomalacia in infants.

Laryngomalacia is the most prevalent cause of congenital stridor. Flexible laryngobronchoscopy (FLB) is the gold standard for diagnosis. However, FLB requires venous access, deep sedation or general anesthesia, and is associated with patient's and parental discomfort and a considerable cost. Laryngeal ultrasound (LUS) has been shown to provide good evaluation of the normal anatomy and the dynamic motion of laryngeal structures. We investigated the yield of LUS in the diagnosis of laryngomalacia in infants with congenital stridor compared to FLB. A prospective blind study of consecutive infants referred for FLB due to congenital stridor with unknown cause. The presence of arytenoids adduction on LUS during inspiration was used to diagnose laryngomalacia. LUS was followed by FLB under anesthesia. The physician performing the FLB was blinded to the LUS results. Twenty-four patients participated in the study (54% males). Median (IQR) age and weight were 3.5 (1-7.7) months and 5.1 (4-8.4) kg, respectively. LUS was well tolerated in all infants. Compared to FLB, LUS correctly diagnosed laryngomalacia in 11/14 (78.6%) infants. In 10 infants FLB ruled out laryngomalacia of whom LUS concurred in 9 infants and one was falsely diagnosed with laryngomalacia. LUS had a sensitivity of 78.5% (CI 52-95%), specificity of 90% (CI 49-94%), NPV of 75%, and PPV of 92%. ROC analysis demonstrated AUC of 0.84 (P < 0.01, 95%CI: 0.67-1.0). We suggest that LUS has a role in screening congenital stridor in otherwise healthy infants when laryngomalacia is highly probable.

Transcutaneous Laryngeal Ultrasonography for Laryngeal Immobility Diagnosis in Patients with Voice Disorders After Thyroid/Parathyroid Surgery.

Transcutaneous laryngeal ultrasonography (TLUS) was recently developed to assess recurrent nerve palsy after thyroid/parathyroid surgery, with variable rates of efficiency. The aim of the current study was to evaluate this technique using subjective estimation and post-processing quantitative data. Fifty subjects presenting with a recurrent nerve palsy and 50 "controls" presenting with voice, swallowing, or breathing disorders following thyroid/parathyroid surgery were prospectively included. All of them underwent a flexible laryngoscopy, considered the gold standard, and a ten-second TLUS clip within the 10days following surgery. In addition to the subjective interpretation of vocal fold motion, two quantitative criteria taking into account motion symmetry (symmetry index, SI) and amplitude (mobility index) of the two hemi-larynges were defined on TLUS acquisitions in adduction and abduction. The subjective interpretation provided a sensitivity of 100% and a specificity of 96%, compared to the gold standard. The quantitative criteria provided a sensitivity and specificity of both 82%, when based on SI solely. When combining SI and mobility index, the sensitivity reached 94%, but the specificity fell to 66%. Visual assessment of recurrent nerve palsy using TLUS after thyroid/parathyroid surgery appeared a high sensitive and specific test compared to flexible laryngoscopy. Quantitative criteria are promising and need to be refined to better describe the whole TLUS video clip.

Ultrasonography of the larynx in horses: an update

Laryngeal ultrasonography is a useful adjunctive diagnostic technique for investigation of upper airway disorders in horses. A transcutaneous examination can be completed using equipment that is widely available to the...

Successful Assessment of Vocal Cord Palsy Before Tracheal Extubation by Laryngeal Ultrasonography in a Patient After Esophageal Surgery

Laryngeal ultrasonography has mainly been performed after tracheal extubation. However, improvements in ultrasound technology now allow assessment of vocal cord function even under conditions of endotracheal intubation. We report herein the use of laryngeal ultrasonography in an endotracheally intubated patient after esophagectomy, which allowed us to make the presumptive diagnosis of bilateral recurrent nerve palsy before tracheal extubation. Our experience suggests that laryngeal ultrasonography may be useful in assessing vocal cord function even in endotracheally intubated patients, although the indications and efficacy remain to be determined.

Laryngeal ultrasound versus cuff leak test in prediction of post-extubation stridor

BackgroundCuff leak test (CLT) has been proposed as a simple method of predicting post-extubation stridor (PES), however due to different cut-off point of cuff-leak volume between previous studies, the laryngeal ultrasonography (US) including measurement of air column width was used to predict PES. The aim of the present study was to evaluate the value of laryngeal US versus cuff leak test in predicting PES. MethodsThe study included fifty patients admitted to the Critical Care Department, Cairo University Hospitals from the period of November 2014 to January 2016, intubated for at least 24 h and examined prior to extubation using CLT and laryngeal ultrasound. ResultsFour cases developed PES. CLT identified PES patients with a sensitivity of 75%, with PPV of 50% for leakage volume of 132.5 ml. Laryngeal ultrasound showed a sensitivity of 50% for those patients with air column width before deflation less than 10.955 mm and air column width difference (ACWD) of 0.905 mm with PPV of 11.8% and 14.3% for both respectively. ConclusionBoth CLT and laryngeal US might have low sensitivity and PPV in predicting PES and should be used with caution in prediction of PES.

A Novel Gel Pad Laryngeal Ultrasound for Vocal Cord Evaluation.

Laryngeal ultrasound (LUS) is a new method for vocal cord evaluation in patients with risk of vocal cord palsy (VCP). However, the previously described LUS reportedly had a high failure rate of vocal cord visualization in male patients. A novel gel pad LUS was devised to overcome the limitations of the previous method. A total of 482 (100 male) consecutive LUS and direct laryngoscopy examinations were performed in thyroidectomy and other neck surgery patients. The conventional LUS and gel pad LUS were used for all patients. Findings were independently cross-validated with direct laryngoscopy. The conventional LUS and gel pad LUS methods had a 93.4% and 99.0% visualization rate, respectively, with a sensitivity of 98.0% for both methods, and a specificity of 99.7% and 99.8%, respectively. Among the 482 patients, 51 patients had VCP and 91 patients had diffuse thyroid cartilage calcification interrupting LUS. The new gel pad LUS method significantly enhances the visualization of vocal cords in patients who have diffuse thyroid cartilage calcification interrupting LUS and, therefore, the overall efficacy of LUS as a perioperative diagnostic tool for VCP.

Lessons Learned After 1000 Cases of Transcutaneous Laryngeal Ultrasound (TLUSG) with Laryngoscopic Validation: Is There a Role of TLUSG in Patients Indicated for Laryngoscopic Examination Before Thyroidectomy?

Patients with hoarseness of voice, previous neck operation, or suspicion of malignancy are at high risk of having pre-thyroidectomy vocal cord (VCP) palsy. Therefore, vocal cord (VC) functions should be evaluated before surgery. This study aimed to evaluate the accuracy of hoarseness, a voice-related questionnaire (Voice Handicap Index [VHI]-30), and transcutaneous laryngeal ultrasound (TLUSG) in diagnosing VCP, as well as the role of TLUSG in the evaluation of high-risk patients. A total of 1000 patients undergoing thyroidectomy or other endocrine-related neck procedures were prospectively included. Symptoms of hoarseness, the VHI-30 score, and TLUSG were evaluated. Validation laryngoscopies were performed by a separate endoscopist after performing TLUSG. All the assessments were performed one to seven days before surgery. The findings of hoarseness, the VHI-30 score, and TLUSG were correlated with laryngoscopic findings to evaluate the diagnostic accuracy. Of 1000 patients, nine preoperative VCP were diagnosed with laryngoscopy. Sensitivity in detecting VCP by hoarseness, the VHI-30 score, and TLUSG were 33.3%, 62.5%, and 88.9%, respectively. A total of 342 patients were considered as high risk, and eight preoperative VCP were confirmed with laryngoscopy. Despite it not being possible to visualize the VCs in 26 (7.7%) patients, TLUSG had a higher accuracy in detecting VCP than the VHI-30 did (96.8% vs. 74.2%; p < 0.001). If patients had been selected who were unassessable or who had had VCP on assessment for confirmatory laryngoscopy, TLUSG saved more patients from laryngoscopic examinations than the VHI-30 did (87.7% vs. 71.3%; p < 0.001). A history of neck operation and suspicion of malignancy did not affect the assessment by TLUSG (p > 0.05). TLUSG is a feasible, non-invasive, and sensitive tool in detecting VCP in high-risk patients. It has safely precluded 87.7% high-risk patients from laryngoscopy. TLUSG should be incorporated as a part of the ultrasound examination of the thyroid.

Learning Curve with Utilization of Transcutaneous Laryngeal Ultrasonography as a Substitute to Standard Laryngoscopy in Perioperative Evaluation of Vocal Cord Function

Learning Curve with Utilization of Transcutaneous Laryngeal Ultrasonography as a Substitute to Standard Laryngoscopy in Perioperative Evaluation of Vocal Cord Function

Laryngeal ultrasound and pediatric vocal fold nodules.

The term vocal fold nodules refers to bilateral thickening of the membranous folds with minimal impairment of the vibratory properties of the mucosa. Nodules are thought to be related to repetitive mechanical stress, associated with voice use patterns. Diagnosis is typically made in the office via either rigid or flexible laryngeal stroboscopy. Depending on the individual child, obtaining an optimal view of the larynx can be difficult if not impossible. Recent advances in high-frequency ultrasonography allows for transcervical examination of laryngeal structures. The goal of this project was to determine if laryngeal ultrasound (LUS) can be used to identify vocal fold nodules in dysphonic children. Prospective case-control study in which the patient acted as his or her own control. Forty-six pediatric patients were recruited for participation in this study; the mean age was 4.8 years. Twenty-three did not have any vocal fold lesions and 23 had a diagnosis of vocal fold nodules on laryngeal stroboscopy. Recorded LUSs were reviewed by two pediatric radiologists who were blinded to the nodule status. There was substantial inter-rater agreement (κ = 0.70, 95% confidence interval [CI]: 0.50-0.89) between the two radiologists regarding the presence of nodules. There was also substantial agreement (κ = 0.87, 95% CI: 0.72-1) between LUS and laryngeal stroboscopy. Sensitivity of LUS was 100% (95% CI: 85%-100%) and specificity was 87% (95% CI: 66%-97%). LUS can be used to identify vocal fold nodules in children with substantial agreement with laryngeal stroboscopy. 3b Laryngoscope, 127:676-678, 2017.

Laryngeal ultrasound and vocal fold movement in the pediatric cardiovascular intensive care unit.

Vocal fold motion impairment (VFMI) is a known sequela of cardiovascular surgery. The gold standard for the evaluation of vocal fold movement is flexible nasolaryngoscopy (FNL). Although safe, FNL does cause measurable physiologic changes. Noxious stimuli in cardiovascular intensive care unit (CVICU) neonates may cause imbalance between the pulmonary and systemic circulations and potentially circulatory collapse. The goals of this project were to determine the accuracy of laryngeal ultrasound (LUS) compared to FNL to identify VFMI in CVICU neonates and compare their physiologic impact. Case control. Prospective case-control study. Forty-six consecutive infants from the CVICU were recruited, 23 with VFMI and 23 without based on FNL findings. They then underwent LUS, which was subsequently reviewed by two pediatric radiologists blinded to the FNL results. Physiologic parameters were recorded before and after the procedures. Data analysis was performed with Cohen's kappa and Wilcoxon signed-rank test. Agreement between LUS and FNL was substantial (κ = 0.78). Laryngeal ultrasound had a sensitivity of 0.84 and specificity of 0.95 for identifying VFMI. In terms of physiologic impact, LUS caused statistically significantly less change in diastolic blood pressure (P = 0.01), pulse (P = 0.001), and O2 saturation (P = 0.004) compared to FNL. Arytenoid rotation could be seen clearly, and the vocal fold-arytenoid angle in abduction was most predictive of symmetry and movement (P = 0.17). However, it was difficult to determine vocal fold closure patterns with LUS. Laryngeal ultrasound is a comparable to FNL for evaluating vocal fold mobility with less physiologic impact. 3b. Laryngoscope, 127:167-172, 2017.

Transcutaneous Ultrasonography in Early Postoperative Diagnosis of Vocal Cord Palsy After Total Thyroidectomy

This study evaluated the efficiency of transcutaneous laryngeal ultrasonography (TLUS) as an alternative to direct flexible laryngoscopy (DFL) in the early postoperative screening of vocal cord palsy (VCP) after total thyroidectomy, performed for benign and non-extensive malignant disease. A prospective study was performed on patients who underwent total thyroidectomy between October 2013 and January 2015 at the Nantes University Hospital (France). Patients underwent DFL on postoperative day 1 performed by an otolaryngologist, followed by TLUS performed by a radiologist on postoperative day 1 or 2. One hundred and three (103) patients were included in this study, 17.5% were male and 82.5% were female, with a mean age of 51 ± 12 years. Nine patients (9.5%) were diagnosed with postoperative VCP using DFL of these cases 2 were not completely resolved at 3 months postoperatively. Three cases of VCP (33%) were diagnosed using TLUS. TLUS had a sensitivity of 33% and a negative predictive value (NPV) of 95% for the diagnosis of postoperative VCP. Vocal cords (VC) were unassessable in 27.2% of patients. Unassessable VC were significantly associated with male gender (p = 0.0001), age (p = 0.0001), weight (p = 0.002), operating time (p = 0.032), postoperative drainage (p = 0.001), and thyroid weight (p = 0.001). Independent risk factors in the multivariate analysis were male gender (p = 0.0001) and age (p = 0.0001). In the group of women under 50-year old, TLUS had a sensitivity of 50% and a NPV of 97.4%. TLUS sensitivity is insufficient in early postoperative screening of VCP after thyroid surgery. Ultrasonographic VCP diagnosis should be confirmed with DFL.

Assessment of Vocal Fold Function Using Transcutaneous Laryngeal Ultrasonography and Flexible Laryngoscopy.

Evaluation of preoperative and postoperative vocal fold function is important in patients undergoing thyroid or parathyroid surgical procedures. Transcutaneous laryngeal ultrasonography (TLUSG) has been proposed as a promising noninvasive technique and alternative to flexible fiberoptic laryngoscopy. To determine whether TLUSG can be an alternative to flexible laryngoscopy in evaluating vocal fold function. A prospective study was performed from March 1, 2013, to July 31, 2014. Patients who were scheduled to undergo thyroid or parathyroid surgery by a single surgeon at a North American, university-based tertiary care center and who agreed to undergo preoperative and postoperative TLUSG and flexible fiberoptic laryngoscopy were enrolled. Patients were divided into 2 groups: nonoverweight (body mass index [calculated as weight in kilograms divided by height in meters squared] <25) and overweight or obese (body mass index ≥ 25). Follow-up was completed on February 28, 2015, and data were analyzed from March 1, 2013, to February 28, 2015. Preoperative and postoperative TLUSG and flexible fiber optic laryngoscopic assessments of vocal fold function. The findings of TLUSG and flexible fiber optic laryngoscopy were compared for all patients and each body mass index group to assess the accuracy of TLUSG in assessing vocal fold function. A total of 250 patients (500 vocal folds) underwent evaluation, of whom 208 (83.2%) were women and with a mean (SD) age of 52.7 (14.3) years. On flexible fiberoptic laryngoscopy findings, 13 patients had preoperative vocal fold paralysis (VFP), and 14 postoperative new incidents of VFP were identified. Only 7 (53.9%) of the preoperative cases of VFP and 15 (55.6%) of the postoperative cases of VFP were identified by TLUSG. The sensitivity, specificity, and accuracy of preoperative TLUSG were 53.8%, 50.5%, and 50.6%, respectively; for postoperative TLUSG, 55.6%, 38.7%, and 39.6%, respectively. In the nonoverweight group, the preoperative TLUSG sensitivity, specificity, and accuracy were 100%, 70.0%, and 70.5%, respectively; in the overweight-obese group, 45.4%, 43.4%, and 43.5%, respectively (odds ratio, 3.16; 95% CI, 2.06-4.84; P < .001). Postoperative visualization of the vocal folds was more challenging, with a sensitivity, specificity, and accuracy of 83.3%, 55.6%, and 56.8%, respectively, in the nonoverweight group, and 47.6%, 32.6%, and 33.4%, respectively, in the overweight-obese group (odds ratio, 2.62; 95% CI, 1.75-3.94; P < .001). When evaluation of vocal fold function is indicated in patients undergoing thyroid and parathyroid surgery, TLUSG should not be considered as an alternative to the current practice of flexible fiberoptic laryngoscopy. Adequate ultrasonographic visualization of the vocal folds and arytenoids is challenging, especially in overweight and obese patients and in the postoperative setting.

Determining the Learning Curve of Transcutaneous Laryngeal Ultrasound in Vocal Cord Assessment by CUSUM Analysis of Eight Surgical Residents: When to Abandon Laryngoscopy.

Transcutaneous laryngeal ultrasonography (TLUSG) is a promising alternative to laryngoscopy in vocal cords (VCs) assessment which might be challenging in the beginning. However, it remains unclear when an assessor can provide proficient TLUSG enough to abandon direct laryngoscopy . Eight surgical residents (SRs) without prior USG experience were recruited to determine the learning curve. After a standardized training program, SRs would perform 80 consecutive peri-operative VCs assessment using TLUSG. Performances of SRs were quantitatively evaluated by a composite performance score (lower score representing better performance) which comprised total examination time (in seconds), VCs visualization, and assessment accuracy. Cumulative sum (CUSUM) chart was then used to evaluate learning curve. Diagnostic accuracy and demographic data between every twentieth TLUSG were compared. 640 TLUSG examinations had been performed by 8 residents. 95.1% of VCs could be assessed by SRs. The CUSUM curve showed a rising pattern (learning phase) until 7th TLUSG and then flattened. The curve declined continuously after 42nd TLUSG (after reaching a plateau). Rates of assessable VCs were comparable in every twentieth cases performed. It took a longer time to complete TLUSG in 1st-20th than 21st-40th examinations. (45 vs. 32s, p = 0.001). Although statistically not significant, proportion of false-negative results was higher in 21st-40th (2.5%) than 1(st)-20th (0.6%), 41(st)-60th (0.7%), and 61(st)-80th (0.7%) TLUSG performed. After a short formal training, surgeons could master skill in TLUSG after seven examination and assess vocal cord function consistently and accurately after 40 TLUSG.

Using Transcutaneous Laryngeal Ultrasonography (TLUSG) to Assess Post-thyroidectomy Patients' Vocal Cords: Which Maneuver Best Optimizes Visualization and Assessment Accuracy?

To assess vocal cord (VC) movement with transcutaneous laryngeal ultrasound (TLUSG), three maneuvers, namely passive (quiet respiration), active (phonation), and Valsalva maneuvers have been described. It remains unclear which maneuver or using more maneuvers provides better visualization and assessment accuracy. We prospectively evaluated 342 post-thyroidectomy patients from two centers. They underwent TLUSG with direct laryngoscopic (DL) validation afterwards. During TLUSG, patients were instructed to perform all three maneuvers (passive, active, and Valsalva). VC visualization rate and accuracy between three maneuvers were compared. Visualization rate tended to be higher in Valsalva maneuver than that in other two maneuvers (92.1% vs. passive: 91.5%; active: 89.8%). While 19 patients had post-operative VC palsy, passive maneuver had lower test specificity than active (94.3 vs. 97.6%, p = 0.01) and Valsalva maneuvers (94.3 vs. 97.4%, p = 0.02). In assessable VCs, passive maneuver has a higher ability to differentiate between mobile VCs and VC palsy (Area under ROC curve--passive: 0.942, active: 0.863, Valsalva: 0.893). TLUSG with more maneuvers did not improve sensitivity or specificity. On applying TLUSG as a screening tool (i.e., only selected patient with "unassessable" VCs or VCP on TLUSG for DL), Valsalva maneuver (85.96%) saved more patients from DL than passive (81.87%) or active (84.81%) maneuver. Passive maneuver has a higher ability to differentiate VC palsy from normal. Using TLUSG as a screening tool, Valsalva was the preferred maneuver as it was more specific, had high visualization rate, and saved more patients from DL.

A novel lateral-approach laryngeal ultrasonography for vocal cord evaluation

Laryngeal ultrasonography (LUS) is a new method of vocal cord (VC) evaluation in patients with risk of vocal cord palsy (VCP). The previously described anterior-approach LUS reportedly, however, has high failure rate of VC visualization in male patients. We devised a novel lateral-approach LUS to overcome this limitation. A total of 382 (82 male, 300 female) consecutive LUS and direct laryngoscopy (DL) examinations were performed on perioperative thyroidectomy and parathyroidectomy patients. The anterior-approach LUS was used for female patients whereas the lateral-approach LUS was used for male patients. Findings were cross-validated independently with DL examinations. Both anterior and lateral LUS methods had 100% visualization rate (no failed visualization) with an overall sensitivity of 100% (23/23) and specificity of 99.2% (356/359) for VCP. Among the 300 female patients, 18 patients had VCP. Sensitivity and specificity of anterior-approach LUS were 100% (18/18) and 99.3% (280/282), respectively. Among the 80 male patients, 5 patients had VCP. Sensitivity and specificity of lateral-approach LU were 100% (5/5) and 98.7% (76/77), respectively. The new LUS approach significantly enhances the visualization of vocal cords and, therefore, overall diagnostic efficacy of LUS in male patients.

The importance of sonographic landmarks by transcutaneous laryngeal ultrasonography in post-thyroidectomy vocal cord assessment

During examination of the vocal cords (VC) using transcutaneous laryngeal ultrasonography (TLUSG), 3 sonographic landmarks (namely, false VC [FC], true VC [TC], and arytenoids [AR]) are often seen. However, it remains unclear which landmark provides a more reliable assessment and whether seeing more landmarks improves the diagnostic accuracy and reliability. We evaluated prospectively 245 patients from 2 centers. One assessor from each center performed all TLUSG examinations and their findings were validated by direct laryngoscopy. All 3 sonographic landmarks were routinely visualized whenever possible. The rate of visualization and diagnostic accuracy between the 3 landmarks were compared. Eighteen patients suffered postoperative VC palsy (VCP). Both centers had comparable visualization or assessability rate of ≥ 1 sonographic landmark (94.9 and 95.3%; P = 1.000) and 100% sensitivity on postoperative TLUSG. The rates of FC, TC, and AR visualization were 92.7%, 36.7%, and 89.8%, respectively. The sensitivity, specificity, and diagnostic accuracy and the proportion of true positives, false positives, and true negatives between using 1, 2, landmarks and 3 landmarks were comparable (P > .05). Each sonographic landmark had similar reliability and diagnostic accuracy. Identifying all 3 sonographic landmarks was not mandatory and visualizing normal movement in one of the sonographic landmarks would be sufficient to exclude VCP.

A Clinical Prediction Tool for Prognosis in Patients with Cystic Fibrosis, Short-Term Glucocorticoid Therapy for Chronic Obstructive Pulmonary Disease, and Laryngeal Ultrasound for Prediction of Postextubation Laryngeal Edema

A Clinical Prediction Tool for Prognosis in Patients with Cystic Fibrosis, Short-Term Glucocorticoid Therapy for Chronic Obstructive Pulmonary Disease, and Laryngeal Ultrasound for Prediction of Postextubation Laryngeal Edema