Vocal Fold Motion Impairment Research Articles

Predictors of enteral tube dependence in pediatric esophageal atresia.

Children with esophageal atresia (EA) may require enteral tube feedings in infancy and a subset experience ongoing feeding difficulties and enteral tube dependence. Predictors of enteral tube dependence have never been systematically explored in this population. We hypothesized that enteral tube dependence is multifactorial in nature, with likely important contributions from anastomotic stricture. Cross-sectional clinical, feeding, and endoscopic data were extracted from a prospectively collected database of endoscopies performed in EA patients between August 2019 and August 2021 at an international referral center for EA management. Clinical factors known or hypothesized to contribute to esophageal dysphagia, oropharyngeal dysphagia, or other difficulties in meeting caloric needs were incorporated into regression models for statistical analysis. Significant predictors of enteral tube dependence were statistically identified. Three-hundred thirty children with EA were eligible for analysis. Ninety-seven were dependent on enteral tube feeds. Younger age, lower weight Z scores, long gap atresia, neurodevelopmental risk factor(s), significant cardiac disease, vocal fold movement impairment, and smaller esophageal anastomotic diameter were significantly associated with enteral tube dependence in univariate analyses; only weight Z scores, vocal fold movement impairment, and anastomotic diameter retained significance in a multivariable logistic regression model. In the current study, anastomotic stricture is the only potentially modifiable significant predictor of enteral tube dependence that is identified.

Ingredients in the Visual Perception of Hypomobile Vocal Fold Motion Impairment.

The clinical determination of vocal fold (VF) hypomobility based on laryngoscopy is subjective. Previous studies point to VF motion anomaly as the most commonly reported factor in the diagnosis of hypomobility. This study tested the hypotheses that VF angular velocities and angular range of motion (ROM) differ between the two VFs in cases of unilateral VF hypomobility. Retrospective. Semi-automated analysis of laryngoscopic videos of 18 subjects diagnosed with unilateral VF hypomobility and 13 subjects with normal VF mobility was performed to quantify/compare the VF angular velocity and ROM between the two VFs during /i/-sniff and laugh. In the hypomobile VF group, 7 out of 15 (47%) videos with /i/-sniff and 5 out of 8 (63%) with laugh had a statistically significant difference in the angular velocities between the VFs in either abduction or adduction. For VF ROM, 8 out of 15 (53%) /i/-sniff videos and 4 out of 8 (50%) with laughter had a statistically significant difference between VFs. In the group without the diagnosis of VF hypomobility, 9 out of 13 subjects (69%) had no difference in VF angular velocity and ROM during either /i/-sniff or laugh. Differences in VF angular velocity or ROM are measurable in a substantial subset of subjects diagnosed with unilateral VF hypomobility. Clinicians' ability to gauge VF motion goes beyond what can be extracted from frame-by-frame analysis. Other visual cues, in addition to VF angular velocity and ROM, likely contribute to the perception of unilateral VF hypomobility. 3 Laryngoscope, 133:866-874, 2023.

Evaluation of Laryngeal Motor Neuropathy Using Transcranial Magnetic Stimulation-Mediated Evoked Potentials.

Contemporary evaluation of vocal fold motion impairment largely relies on clinical laryngoscopy, with the diagnoses of vocal fold paresis (VFPa) and paralysis (VFP) being based on identification of partial and complete restriction of gross vocal fold motion, respectively. No consensus exists on the diagnostic criteria of VFPa. Laryngeal electromyography does not offer any insight into nerve conduction velocity without the adjunction of nerve conduction studies, which are impractical to perform on laryngeal nerves due to their anatomic location. The present study aims to assess the feasibility of laryngeal nerve conduction studies using transcranial magnetic stimulation (TMS)-mediated myogenic evoked potentials in the evaluation of laryngeal motor nerve function. Prospective controlled cohort study. Enrollment of three groups of subjects defined as healthy volunteers, subjects with clinically diagnosed unilateral VFP, and subjects with clinically diagnosed unilateral VFPa of peripheral etiology. Electrodiagnostic studies consisting of bilateral stimulation of the laryngeal motor cortex, proximal cisternal, and peripheral portions of the vagus nerves were performed using figure-of-eight magnetic stimulation coils, and myogenic evoked potentials recorded from bilateral thyroarytenoid, cricothyroid, and posterior cricoarytenoid muscles using indwelling hook wire electrodes. Conduction latencies were plotted against demographic and anthropometric variables. Values obtained in healthy volunteers were used as normative references and compared to aggregated latencies of VFP and VFPa groups. Enrolled subjects included 19 healthy volunteers, 5 subjects with VFP, and 4 subjects with VFPa. Normative laryngeal nerve conduction latency ranges measured in healthy subjects were comparable to prior published values, and recorded latencies increased in positive correlation with age. VFPa subjects exhibited increased latencies in affected nerve sites, while VFP subjects presented more variability in electrophysiologic manifestations, mostly dependent on their degree of compensatory reinnervation. Aberrant and synkinetic reinnervation patterns were more predominant in the VFP group than the VFPa group. Laryngeal nerve conduction studies using TMS-mediated myogenic evoked potentials are safely feasible. They may serve as a useful complement to laryngeal electromyography in the evaluation of motor laryngeal neuropathy and represent a promising diagnostic modality in the evaluation of VFPa. Based on the present study's findings, the commonly accepted notion of VFPa as a manifestation of a less severe form of neuropathy than VFP may be unsubstantiated. Aging may contribute to progressive motor nerve dysfunction. Future investigations are needed to ascertain the role of nerve conduction studies in clinical laryngology practice. 3 Laryngoscope, 132:S1-S12, 2022.

Inpatient Type 1 Thyroplasty Versus Injection Laryngoplasty for Vocal Fold Movement Impairment After Extent type I and II Aortic Repair.

Vocal fold motion impairment (VFMI) due to neuronal injury is a known complication following thoracic aortic repair that can impair pulmonary toilet function and post-operative recovery. To demonstrate clinical outcomes of patients undergoing inpatient vocal fold medialization for VFMI after aortic surgery. A 15-year retrospective chart review (2005-2019) of 259 patients with postoperative VFMI after thoracic aortic surgery registry was conducted. Data included demographics, surgery characteristics, laryngology exam, and postoperative clinical outcomes. Medialization procedures consisted of type 1 thyroplasty and injection laryngoplasty. Tertiary care hospital. Two hundred and fifty-nine patients (median age 61, 71% male) with VFMI post-thoracic aortic repair met inclusion criteria; inpatient vocal fold medialization was performed for 203 (78%) patients. One hundred and twenty-six. (49%) received type 1 thyroplasty and 77 (30%) received injection laryngoplasty procedures at a median 7 days (IQR 5-8 days) from extubation. Primary study outcome measurements consisted of median LOS, median ICU LOS, complications intra- and postoperatively, and pulmonary complications (post-medialization bronchoscopies, pneumonia, tracheostomy, etc.). Post-medialization bronchoscopy rates were significantly lower in the medialization (n = 11) versus the non-medialization group (n = 8) (5% vs 14%, P = .02) and significantly higher in the injection laryngoplasty group (n = 77) versus thyroplasty group (n = 126) (10% vs 2%, P = .02). Further analysis revealed no significant difference in overall LOS and pulmonary complications between the techniques. Inpatient thyroplasty and injection laryngoplasty are both effective vocal fold medialization techniques after extent I and II aortic repair. Thyroplasty may have a small pulmonary toilet advantage, as measured by need for post-medialization bronchoscopy, compared to injection laryngoplasty.

Prognostic Indicators of Non-Transection Nerve Injury and Vocal Fold Motion Impairment After Thyroid Surgery - Correlation Between Intraoperative Neuromonitoring Findings and Perioperative Voice Parameters.

ObjectivesIn patients with recurrent laryngeal nerve (RLN) injury after thyroid surgery, unrecovered vocal fold motion (VFM) and subjective voice impairment cause extreme distress. For surgeons, treating these poor outcomes is extremely challenging. To enable early treatment of VFM impairment, this study evaluated prognostic indicators of non-transection RLN injury and VFM impairment after thyroid surgery and evaluated correlations between intraoperative neuromonitoring (IONM) findings and perioperative voice parameters.Methods82 adult patients had postoperative VFM impairment after thyroidectomy were enrolled. Demographic characteristics, RLN electromyography (EMG), and RLN injury mechanism were compared. Multi-dimensional voice program, voice range profile and Index of voice and swallowing handicap of thyroidectomy (IVST) were administered during I-preoperative; II-immediate, III-short-term and IV-long-term postoperative periods. The patients were divided into R/U Group according to the VFM was recovered/unrecovered 3 months after surgery. The patients in U Group were divided into U1/U2 Group according to total IVST score change was <4 and ≥4 during period-IV.ResultsCompared to R Group (42 patients), U Group (38 patients) had significantly more patients with EMG >90% decrease in the injured RLN (p<0.001) and thermal injury as the RLN injury mechanism (p=0.002). Voice parameter impairments were more severe in U Group compared to R Group. Compared to U1 group (19 patients), U2 Group (19 patients) had a significantly larger proportion of patients with EMG decrease >90% in the injured RLN (p=0.022) and thermal injury as the RLN injury mechanism (p=0.017). A large pitch range decrease in period-II was a prognostic indicator of a moderate/severe long-term postoperative subjective voice impairment.ConclusionThis study is the first to evaluate correlations between IONM findings and voice outcomes in patients with VFM impairment after thyroid surgery. Thyroid surgeons should make every effort to avoid severe type RLN injury (e.g., thermal injury or injury causing EMG decrease >90%), which raises the risk of unrecovered VFM and moderate/severe long-term postoperative subjective voice impairment. Using objective voice parameters (e.g., pitch range) as prognostic indicators not only enables surgeons to earlier identify patients with low voice satisfaction after surgery, and also enable implementation of interventions sufficiently early to maintain quality of life.

Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery.

Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection. Retrospective chart review. This is a retrospective chart review of infants (age <12 months) who underwent congenital heart surgery between 7/2008 and 1/2018 and received a subsequent videofluoroscopic swallow study (VFSS). Demographic information, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of each surgery, vocal fold mobility status, and VFSS findings were collected and analyzed. Three hundred and seventy-four patients were included in the study. Fifty-four percent of patients were male, 24% were premature, and the average age at the time of VFSS was 59 days. Sixty percent of patients had oral dysphagia and 64% of patients had pharyngeal dysphagia. Fifty-one percent of patients had laryngeal penetration and 45% had tracheal aspiration. Seventy-three percent of these aspirations were silent. There was no association between surgical complexity, as defined by the STAT category, and dysphagia or airway protection findings. Patients with VFMI after surgery were more likely to have silent aspiration (odds ratio=1.94, P < .01), even when adjusting for other risk factors. Infants who undergo congenital heart surgery are at high risk for VFMI and aspiration across all five STAT categories. This study demonstrates the high prevalence of silent aspiration in this population and the need for thorough postoperative swallow evaluation. 4 Laryngoscope, 132:701-705, 2022.

Postacute COVID‐19 Laryngeal Injury and Dysfunction

ObjectivePatients with COVID-19 are at risk for laryngeal injury and dysfunction secondary to respiratory failure, prolonged intubation, and other unique facets of this illness. Our goal is to report clinical features and treatment for patients presenting with voice, airway, and/or swallowing concerns postacute COVID-19.Study DesignCase series.SettingAcademic tertiary care center.MethodsPatients presenting with laryngeal issues following recovery from COVID-19 were included after evaluation by our laryngology team. Data were collected via retrospective chart review from March 1, 2020, to April 1, 2021. This included details of the patient’s COVID-19 course, initial presentation to laryngology, and subsequent treatment.ResultsTwenty-four patients met inclusion criteria. Twenty (83%) patients were hospitalized, and 18 required endotracheal intubation for a median (range) duration of 14 days (6-31). Ten patients underwent tracheostomy. Patients were evaluated at a median 107 days (32-215) after their positive SARS-CoV-2 test result. The most common presenting concerns were dysphonia (n = 19, 79%), dyspnea (n = 17, 71%), and dysphagia (n = 6, 25%). Vocal fold motion impairment (50%), early glottic injury (39%), subglottic/tracheal stenosis (22%), and posterior glottic stenosis (17%) were identified in patients who required endotracheal intubation. Patients who did not need intubation were most frequently treated for muscle tension dysphonia (67%).ConclusionPatients may develop significant voice, airway, and/or swallowing issues postacute COVID-19. These complications are not limited to patients requiring intubation or tracheostomy. Multidisciplinary laryngology clinics will continue to play an integral role in diagnosing and treating patients with COVID-19–related laryngeal sequelae.

Triological Best Practice: Should Bedside Laryngoscopy Be Routinely Performed Following Thyroidectomy?

Triological Best Practice: Should Bedside Laryngoscopy Be Routinely Performed Following Thyroidectomy?

Vocal cord palsy as a sequela of paediatric cardiac surgery – a review

Vocal cord palsy is one of the recognised complications of complex cardiac surgery in the paediatric population. While there is an abundance of literature highlighting the presence of this complication, there is a scarcity of research focusing on the pathophysiology, presentation, diagnosis, and treatment options available for children affected by vocal cord palsy. Electronic searches were conducted using the search terms: "Vocal Cord Palsy," "VCP," "Vocal Cord Injury," "Paediatric Heart Surgery," "Congenital Heart Surgery," "Pediatric Heart Surgery," "Vocal Fold Movement Impairment," "VFMI," "Vocal Fold Palsy," "PDA Ligation." The inclusion criteria were any articles discussing the outcomes of vocal cord palsy following paediatric cardiac surgery. The two main populations affected by vocal cord palsy are children undergoing aortic arch surgery or those undergoing PDA ligation. There is paucity of prospective follow-up studies; it is therefore difficult to reliably assess the current approaches and the long-term implications of management options. Vocal cord palsy can be a devastating complication following cardiac surgery, which if left untreated, could potentially result in debilitation of quality of life and in severe circumstances could even lead to death. Currently, there is not enough high-quality evidence in the literature to aid recognition, diagnosis, and management leaving clinicians to extrapolate evidence from adult studies to make clinical judgements. Future research with a focus on the paediatric perspective is necessary in providing evidence for good standards of care.

Pediatric Unilateral Vocal Fold Paralysis: Workup and Management

This paper will examine recent advances in the assessment and management of pediatric unilateral vocal fold motion impairment (VFMI). Unilateral VFMI can have a considerable impact on pediatric voice, swallowing, and pulmonary hygiene. In addition, postoperative VFMI in children undergoing congenital cardiac procedures is associated with longer lengths of stay. Laryngeal ultrasound (LUS) is an adjunctive tool that can be used to assess vocal fold mobility in patients who cannot tolerate traditional flexible nasolaryngoscopy (FNL) or for those in whom FNL is non-diagnostic. Laryngeal electromyography (LEMG) can help differentiate neuronal causes of vocal fold paralysis from mechanical cricoarytenoid joint fixation. Recent data suggests that preoperative LEMG may be used to predict voice outcomes after non-selective laryngeal reinnervation (NSLR). NSLR is a promising treatment modality for permanent vocal fold medialization in children. An emphasis on early diagnostic and prognostic techniques, such as the use of LUS and LEMG, can inform decision-making in unilateral VFMI treatment. NSLR is emerging as the preferred treatment modality for pediatric unilateral VFMI due to neuronal injury.

Pediatric Unilateral Vocal Fold Movement Impairment: Diagnostic Tools and Management Strategies

Unilateral vocal fold movement impairment (VFMI) in the pediatric population presents unique challenges. Thoughtful and innovative methods of diagnosis, prognostication, and intervention have recently influenced the management of VFMI in children. This article presents updates on the natural history of pediatric VFMI, use of laryngeal ultrasound (LUS) and laryngeal electromyography (LEMG) as diagnostic tools, and optimal management strategies for pediatric unilateral VFMI. Long-term follow-up studies for pediatric patients diagnosed with VFMI described a substantial number of children that have recovery of VFMI well after 12 months, contradicting the conventional teaching that recovery after 1 year is unlikely. LUS performs well compared to the gold standard flexible nasolaryngoscopy (FNL) in identifying VFMI with significantly less physiologic impact. LEMG can be used to assist in determining etiology of VFMI and may play a role in predicting recovery and outcomes of interventions. Recent data has demonstrated that reinnervation is highly effective in managing dysphonia and aspiration in children with VFMI. Children diagnosed with VFMI should be followed at regularly scheduled intervals until resolution of their VFMI. LUS is an alternate tool that should be considered in medically fragile children susceptible to alterations in physiologic parameters. LEMG is a useful adjunct for elucidating neuronal versus mechanical VFMI. Recent data suggests that reinnervation should be considered as a primary surgical intervention for neuronal unilateral VFMI.

Factors associated to functional recovery of left vocal fold motion impairment at two-years-old age in very preterm infants

ObjectiveTo describe a cohort of neonates with left vocal fold motion impairment (LVFMI) and the factors associated to it in the neonatal period; procedures required during LVFMI treatment; and clinical outcomes at the age of 2-years. An additional objective was to study those factors which are likely to be most associated to functional recovery of LVFMI at this age. MethodsA cohort of patients born in a tertiary care hospital with a diagnosis of left VFMI was included. Factors registered were: gender; clinical presentation at the time of examination; diagnosis of other laryngeal defects associated; data related to their neonatal period (gestational age, congenital heart defects corrective surgery required, neurologic disease, bronchopulmonary dysplasia, non-invasive ventilation required, invasive ventilation required, and tracheostomy required); treatment applied for LVFMI (tracheostomy and/or laryngeal surgery); need of language and hearing therapy; and outcomes considered by the pediatric otolaryngologist at the 2 years-old follow-up visit. ResultsA total of 56 patients with LVFMI diagnosis were included. Only 10 patients (17.9%) showed functional recovery from LVFMI at the age of 2 years. We found significant negative association between this recovery and language and hearing therapy (p = 0.03), which was also associated to psychomotor retardation (p < 0.001). Multivariate analysis produced similar results, being language and hearing therapy the only significant factor associated to a worse outcome (OR = 4.77 [CI95% 1.14; 20.08] p = 0.03). ConclusionPsychomotor development retardation is negatively associated to functional recovery of full speech in a preterm infant's population with LVFMI diagnosis, regardless of other factors related to LVFMI etiology and severity.

Immediate Voice and Swallowing Complaints Following Revision Anterior Cervical Spine Surgery.

To report on the incidence of dysphagia, dysphonia, and acute vocal fold motion impairment (VFMI) following revision anterior cervical spine surgery, as well as to identify risk factors associated with acute VFMI in the immediate postoperative period. Retrospective cohort study. Tertiary care center. All patients who underwent 2-team reoperative anterior cervical discectomy and fusion (ACDF) were retrospectively reviewed. Incidence of dysphonia, dysphagia, and acute VFMI was noted. Patient and operative factors were evaluated for association with risk of acute VFMI. The incidence of postoperative dysphonia and dysphagia was 25% (18/72) and 52% (37/72), respectively. The incidence of immediate VFMI was 21% (15/72). Subjective postoperative dysphonia (odds ratio, [OR] 8; 95% CI, 2.2-28; P = .001) and dysphagia (OR, 22; 95% CI, 2.5-168; P = .005) were significantly associated with increased risk of VFMI. Three patients with VFMI required temporary injection medialization for voice complaints and/or aspiration. Infection (OR, 14; 95% CI, 1.4-147, P = .025) and level C7/T1 (OR, 5.5; 95% CI, 1.3-23, P = .02) were significantly associated with an increased risk of acute VFMI on multivariate logistic regression analysis. Number of prior surgeries, laterality of approach, side of approach relative to prior operations, and number of levels exposed were not significant. Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.

Prevalence and characterisation of vocal fold motion impairment (VFMI) in patients with Multiple system atrophy compared with Parkinson's disease

IntroductionMultiple system atrophy (MSA) is a neurodegenerative disorder in which vocal fold mobility can be affected, sometimes leading to life-threatening situations. Our aim was to know if laryngeal examination could help differentiate MSA from Parkinson's disease (PD). Materials and methodsBetween 2004 to 2014, all consecutive patients diagnosed with probable MSA were included in this retrospective, monocentric study. Flexible laryngoscopy was obtained in 51 MSA patients and compared with 27 patients with Parkinson's disease (PD). Laryngeal muscles EMG was available in 6 MSA patients. ResultsVocal fold motion impairments (VFMI) was found in 35 (68.6%) MSA patients: 15 (29.4%) had uni- or bilateral vocal fold abnormal movement (VFAM), 13 (25.5%) had uni- or bilateral vocal fold abductor paresis (VFABP), 4 (7.8%) had uni- or bilateral vocal fold adductor paresis (VFADP), 10 (19.6%) had bilateral vocal fold paralysis (BVFP). VFMI was found in 13 PD patients (48.1%) all of whom had VFADP. Presence of BVFP was found associated with stridor (P<0.001) and dysphagia (P=0.002). In all muscles examined in 6 MSA patients, the EMG showed neuropathic patterns. ConclusionsOur data support that VFMI may be encountered in two-thirds of MSA with a variable degree of gravity. Laryngological examination should be considered as a supplementary tool for the diagnosis and prognosis of MSA. VFMI in particular VFAM, VFABD and BVFP should be discussed as an additional possible red flag even at an early stage of MSA and could help discriminate MSA from PD.

Heightened risk of early vocal fold motion impairment onset and dysphagia in the parkinsonian variant of multiple system atrophy: a comparative study

ObjectiveWe compared differences in frequency and timing of onset of the following clinical events between the cerebellar and parkinsonian variants of multiple system atrophy (MSA-C and MSA-P, respectively): type of operation including tracheostomy and/or aspiration prevention surgery, vocal fold motion impairment (VFMI), sleep apnea (SA), introduction of mechanical ventilation (MV), and dysphagia. The risks of these events cooccurring with either MSA-C or MSA-P were compared. MethodsWe retrospectively assessed clinical outcomes only of patients with MSA who presented at the Department of Otolaryngology of the University of Tokyo Hospital between 2008 and 2018. The proportion and timing of onset events between MSA-C and MSA-P and risks of onset were compared using chi-square tests and Cox proportional hazard models adjusted for age, sex, and disease severity, respectively. ResultsWe identified 113 patients (median age: 60 years, 72 men [64%]). The frequency and timing of VFMI, SA, MV, dysphagia, and surgeries were 55 patients (49%) and 76 (95% CI 61–91) months after MSA onset, 85 (75%) and 41 (32–50), 36 (32%) and 100 (73–127), 77 (68%) and 43 (36–50), and 25 (22%) and 102 (84–120), respectively. Twenty-seven patients (24%) had MSA-P and higher risk of VFMI (p < .001), SA (p = .030), and dysphagia (p = .017) than did patients with MSA-C. ConclusionWhile MSA-P is less common, it may involve heightened risk of VFMI and dysphagia early onset. Thus, careful follow-up for VFMI, SA, and dysphagia may be needed for these patients. Criteria for Rating Diagnostic Accuracy StudiesClass II.

Point of care, clinician-performed laryngeal ultrasound and pediatric vocal fold movement impairment

IntroductionVocal fold movement impairment (VFMI) is a well-known sequela of cervical and thoracic procedures performed in the vicinity of the recurrent laryngeal nerve. Interpretation of flexible nasolaryngoscopy (FNL) can be difficult in young children due to crying, secretions, and obstructing supraglottic structures. We have previously published on the use of radiologist performed and interpreted, laryngeal ultrasound (LUS) to evaluate vocal fold mobility with substantial agreement with FNL in infants in the cardiovascular intensive care unit. The purpose of this study was to evaluate point of care, clinician performed, LUS for vocal fold mobility in a pediatric voice clinic. MethodsLUS and FNL were performed and recorded on 30 consecutive patients (11 with a clinical diagnosis of VFMI and 19 with clinically normal mobility) in a pediatric voice clinic. All LUS was performed by a single clinician (reviewer 1) with a GE logiq P9 and 12 MHz linear probe. Deidentified recordings of the LUS and FNL (without sound) were reviewed in random order by 2 fellowship trained pediatric otolaryngologists who were blinded to the vocal fold mobility. Cohen's kappa was used to determine agreement. ResultsThere was substantial agreement (κ = 0.7) between the reviewers regarding interpretation of LUS as well as regarding interpretation of FNL κ = 0.7802. In addition, each reviewer had near perfect to substantial agreement between their interpretation of the LUS and FNL (reviewer 1 κ = 0.9294 and reviewer 2 κ = 0.8413). ConclusionPoint of care, clinician performed, LUS can be used for the identification of VFMI with substantial agreement with FNL with good inter-rater reliability. This provides clinicians with another tool in their armamentarium for the evaluation of challenging larynges.

Application-Based Translaryngeal Ultrasound for the Assessment of Vocal Fold Mobility in Children.

To compare the evaluation of vocal fold mobility between flexible nasal laryngoscopy (FNL) and a handheld application-based translaryngeal ultrasound (TLUS) platform. Prospective analysis included patients with unknown vocal fold mobility status who underwent FNL and TLUS. Tertiary referral center. TLUS was performed on 23 consecutive children (<18 years old) presenting for laryngoscopy due to unknown vocal fold mobility status. After the recording of three 10-second TLUS videos as well as FNL, the study was divided into 2 parts: parental assessment of laryngeal ultrasound at the time of patient evaluation and random practitioner assessment of ultrasound videos. We describe 23 patients who underwent TLUS and FNL. Ten patients (43.5%) had normal vocal fold function bilaterally, and 13 (56.5%) had either left or right vocal fold immobility. Family members and physicians correctly identified the presence and laterality of impaired vocal fold mobility in 22 of 23 cases (κ = 0.96). The sensitivity, specificity, positive predictive value, and negative predictive value of FLUS in diagnosing vocal fold immobility were 92.3%, 100%, 100%, and 90.9%, respectively. Random practitioners accurately identified the presence and laterality of vocal fold immobility under all circumstances. A handheld application-based ultrasound platform is both sensitive and specific in its ability to identify vocal fold motion impairment. Portable handheld TLUS has the potential to serve as a validated screening examination, even by inexperienced providers, and in specific cases may obviate the need for an invasive transnasal laryngoscopy.

Predictors of voice outcome in pediatric non-selective laryngeal reinnervation.

Non-selective laryngeal reinnervation (NSLR) using the ansa cervicalis to the recurrent laryngeal nerve (RLN) is a promising treatment option for pediatric unilateral neuronal vocal fold movement impairment (VFMI). The aim is to describe our clinical outcomes with this technique and to identify preoperative characteristics that may predict postoperative voice outcomes. This is a cohort study of pediatric patients with unilateral neuronal VFMI, who underwent NSLR from March 2012 to July 2018. Pre- and postoperative Pediatric Voice Related Quality of Life (PVRQOL) questionnaires, Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) ratings, and objective voice measures were obtained. In addition, patients underwent preoperative laryngeal electromyography (LEMG). Thirty-two patients were identified. Twenty-one had complete data sets for analysis. The mean duration of VFMI was 9.02 years (range 1.1-26.1 years). There were significant improvements in PVRQOL (P = .0005), in all CAPE-V subsets (P ≤ .0001 to .0195), mean and maximum intensities (P = .0342 and 0.0110, respectively), cepstral peak prominence (P = .0001), and cepstral spectral index of dysphonia (P ≤ .0001). A worse preoperative LEMG correlated with a greater change in maximum phonation time (P = .0162) and maximum intensity (P = .0346). Age at injury and duration of injury had no significant impact on voice outcomes; however, patients with concurrent posterior glottic insufficiency did have smaller changes in PVRQOL (P = .012). NSLR is an effective treatment for pediatric unilateral neuronal VFMI even many years after initial RLN injury. LEMG may help predict voice outcomes of reinnervation in pediatric patients, but further data is still needed. 4 Laryngoscope, 130:1525-1531, 2020.

Assessment of Voice Outcomes Following Surgery for Thyroid Cancer

An increasing number of surgeries are being performed for differentiated thyroid cancer (DTC). Long-term voice abnormalities are a known risk of thyroid surgery; however, few studies have used validated scales to quantify voice outcomes after surgery. To identify the prevalence, severity, and factors associated with poor voice outcomes following surgery for DTC. A cross-sectional, population-based survey was distributed via a modified Dillman method to 4185 eligible patients and linked to Surveillance, Epidemiology and End Results (SEER) data from SEER sites in Georgia and Los Angeles, California, from February 1, 2017, to October 31, 2018. Multivariable logistic regression and zero-inflated negative binomial analysis were performed to determine factors associated with abnormal voice. Participants included patients undergoing surgery for DTC between January 1, 2014, and December 31, 2015, excluding those with voice abnormalities before surgery. Abnormal Voice Handicap Index (VHI-10) score, defined as greater than 11. The VHI-10 is designed to quantify 10 psychosocial consequences of voice disorders on a Likert scale (0, never; to 4, always). A total of 2632 patients (63%) responded to the survey and 2325 met the inclusion criteria. With data reported as unweighted number and weighted percentage, 1792 were women (77.4%); weighted mean (SD) age was 49.4 (14.4) years. Of these, 599 patients (25.8%) reported voice changes lasting more than 3 months following surgery, 272 patients (12.7%) were identified as having an abnormal VHI-10 score, and 105 patients (4.7%) reported vocal fold motion impairment diagnosed by laryngoscopy. In multivariable analysis, factors associated with an abnormal VHI-10 score included age 45 to 54 years (reference, ≤44 years; odds ratio [OR], 1.49; 95% CI, 1.05-2.11), black race (OR, 1.73; 95% CI, 1.14-2.62), Asian race (OR, 1.66; 95% CI, 1.08-2.54), gastroesophageal reflux disease (OR, 1.67; 95% CI, 1.15-2.43), and lateral neck dissection (OR, 1.99; 95% CI, 1.11-3.56). A high prevalence of abnormal voice per validation with the VHI-10 emphasizes the need for heightened awareness of voice abnormalities following surgery and warrants consideration in the preoperative risk-benefit discussion, planned extent of surgery, and postoperative rehabilitation.

Inter-rater reliability of seven neurolaryngologists in laryngeal EMG signal interpretation

PurposeLaryngeal electromyography (LEMG) has been considered as gold standard in diagnostics of vocal fold movement impairment, but is still not commonly implemented in clinical routine. Since the signal interpretation of LEMG signals (LEMGs) is often a subjective and semi-quantitative matter, the goal of this study was to evaluate the inter-rater reliability of neurolaryngologists on LEMGs of volitional muscle activity.MethodsFor this study, 52 representative LEMGs of 371 LEMG datasets were selected from a multicenter registry for a blinded evaluation by 7 experienced members of the neurolaryngology working group of the European Laryngological Society (ELS). For the measurement of the observer agreement between two raters, Cohen’s Kappa statistic was calculated. For the interpretation of agreements of diagnoses among the seven examiners, we used the Fleiss’ Kappa statistic.ResultWhen focusing on the categories “no activity”, “single fiber pattern”, and “strongly decreased recruitment pattern”, the inter-rater agreement varied from Cohen’s Kappa values between 0.48 and 0.84, indicating moderate to near-perfect agreement between the rater pairs. Calculating with Fleiss’ Kappa, a value of 0.61 showed good agreement among the seven raters. For the rating categories, the Fleiss’ Kappa value ranged from 0.52 to 0.74, which also showed a good agreement.ConclusionA good inter-rater agreement between the participating neurolaryngologists was achieved in the interpretation of LEMGs. More instructional courses should be offered to broadly implement LEMG as a reliable diagnostic tool in evaluating vocal fold movement disorders in clinical routine and to develop future algorithms for therapy and computer-assisted examination.