Diagnosis and management of unilateral thyroarytenoid muscle palsy.

The objective of this study is to assess and propose a method of diagnosis and management of patients with unilateral thyroarytenoid muscle palsy (TAMP). This is a retrospective review of clinical records. The records of seven patients diagnosed as having idiopathic TAMP were reviewed. Despite the adductive and abductive functions of the vocal folds being within normal range, apparent palsy was seen in the unilateral thyroarytenoid muscle of these patients. TAMP was confirmed by laryngeal electromyography, and the adductive and abductive movements of the vocal folds were evaluated as the mobility of the arytenoid cartilages by three-dimensional computed tomography and endoscopy. Most of patients with TAMP had been diagnosed as having other diseases or normal, and in one patient, it took over 6 years to establish a correct diagnosis. Two patients recovered by conservative treatment; however, in five patients, TAMP remained even after 6 months. In 4 of those 5 patients, treatment with hyaluronic acid injections was performed. In the remaining patient, surgical treatment, namely, nerve-muscle pedicle flap implantation was performed, which resulted in a favorable recovery of phonation. The average maximum phonation time (MPT) of all patients was extended from 11.4 (±4.4) s before treatment to 19.9 (±4.3) s after treatment, and the pitch range was also increased from 25.1 (±7.2) to 34.6 (±5.8) semitones following our management course. Our results indicate that there is a possibility that TAMP can be diagnosed and treated sufficiently. Therefore, further research toward establishing the concept of and treatment for TAMP is anticipated.

Arytenoid cartilage dislocation from external blunt laryngeal trauma: evaluation and therapy without laryngeal electromyography.

BACKGROUND: Intubation trauma is the most common cause of arytenoid dislocation. The aim of this study was to investigate the diagnosis and treatment of arytenoid cartilage dislocation from external blunt laryngeal trauma in the absence of laryngeal electromyography (LEMG) and to explore the role of early attempted closed reduction in arytenoids cartilage reposition. MATERIAL AND METHODS: This 15-year retrospective study recruited 12 patients with suspected arytenoid dislocation from external blunt laryngeal trauma, who were evaluated through 7 approaches: detailed personal history, voice handicap index (VHI) test, indirect laryngoscope, flexible fiberoptic laryngoscope, video strobolaryngoscope, and/or high-resolution computed tomography (CT), and, most importantly, the outcomes after attempted closed reduction under local anesthesia. They were divided into satisfied group (n=9) and dissatisfied group (n=3) based on their satisfied with voice qualities at 1 week after the last closed reduction manipulation. RESULTS: Each patient was diagnosed with arytenoid dislocation caused by external blunt laryngeal trauma. In the satisfied group, VHI scores and maximum phonation time (MPT) at 1 week after the last reduction were significantly improved compared with those before the procedure (P<0.05). Normal or improved mobility and length of the affected vocal fold were also noted immediately after the end of the last closed reduction. The median time interval between injury and clinical intervention in satisfied group was 43.44±34.13 days, much shorter than the median time of 157.67±76.07 days in the dissatisfied group (P<0.05). CONCLUSIONS: Multimodality assessment protocols are essential for suspected arytenoid dislocation after external blunt laryngeal trauma. Early attempted closed reduction should be widely recommended, especially in health facilities without LEMG, mainly, because it could be helpful for early diagnosis and treatment of this disease. In addition, early closed reduction could also improve the success of arytenoid reduction.

Characteristics of vocal fold immobility following endotracheal intubation.

OBJECTIVES: We investigated the clinical and laryngeal electromyography (LEMG) characteristics and the outcome of closed reduction of arytenoid cartilage dislocation in patients with vocal fold immobility (VFI) following endotracheal intubation. METHODS: Sixty patients with VFI following endotracheal intubation were included. Closed reduction was performed under local anesthesia in 54 cases. Another 6 patients did not undergo an intervention. Laryngeal behaviors and voice function were evaluated. Forty-five patients underwent LEMG testing. RESULTS: All patients complained of persistent hoarseness immediately following surgery. The LEMG results for 29 of 45 patients showed normal patterns (15 cases) or mildly abnormal patterns (14 cases) on the affected side. Sixteen cases displayed apparent abnormal LEMG patterns on the affected side. The voices of all 54 patients improved after reduction. The movement of the affected vocal folds recovered to normal in 51 cases. One month after reduction, neuromuscular function had improved in 29 of 30 cases.Among the 6 patients who did not undergo intervention, 3 had normal or slightly hoarse voices, and 3 experienced moderate hoarseness. CONCLUSIONS: Vocal fold immobility following endotracheal intubation is typically caused by arytenoid dislocation. Some instances were accompanied by an abnormality of the recurrent laryngeal nerve. A timely closed arytenoid reduction should be performed to restore patients' normal voices and vocal fold mobility. Our reduction technique under local anesthesia can be performed easily and obtains satisfactory outcomes within 6 weeks after endotracheal intubation.

Detection of passive movement of the arytenoid cartilage in unilateral vocal-fold paralysis by laryngoscopic observation: useful diagnostic findings.

In a previous study of patients with unilateral vocal-fold paralysis (UVFP), three-dimensional computed tomography (3DCT) revealed passive movement during phonation, with the arytenoid cartilage on the paralyzed side pushed to the unaffected side and deviated upwards. The present work compares the 3DCT findings with those obtained by 2-dimensional endoscopy to visualize the vertical passive movement of the arytenoid cartilage. The study population consisted of 23 patients with UVFP and two with laryngeal deviation but normal movement of the vocal folds. Two endoscopic findings represented cranial deviation during phonation: posterior deviation of the arytenoid hump and lateral deviation of the muscular process. These two findings were classified into four grades, ranging from 0 (normal) to 3 (severe). Cranial displacement detected by 3DCT was also classified into four grades. Significant correlations were found between the 3DCT-determined grade of cranial displacement of the arytenoid cartilage and the grade assigned based on the two endoscopic findings. Moreover, lateral deviation of the muscular process was more significantly correlated with 3DCT grade than with endoscopic grade. Thus, endoscopic findings may be useful in the diagnosis of vocal-fold paralysis, and passive lateral deviation of the muscular process as an indicator of UVFP.

Use of intraoperative laryngeal electromyography to evaluate stridor in children with arthrogryposis.

OBJECTIVES: Arthrogryposis is a rare, congenital condition characterized by joint contractures of the extremities with muscle weakness and fibrosis. The otolaryngological manifestations of this disorder may include stridor, chronic aspiration, and Pierre Robin sequence, among others. Prior reports of vocal fold immobility associated with arthrogryposis have attributed it to recurrent laryngeal nerve paralysis, rather than to cricoarytenoid joint restriction. The objective of this study was to determine whether children with arthrogryposis and vocal fold immobility demonstrated laryngeal electromyography (L-EMG) findings consistent with recurrent laryngeal nerve paralysis or with cricoarytenoid joint restriction. METHODS: A retrospective, institutional chart review of children with otolaryngological manifestations of arthrogryposis was performed; 6 children were identified. Three patients had vocal fold immobility documented by flexible laryngoscopy. These 3 children were prospectively evaluated with direct laryngoscopy and intraoperative L-EMG. RESULTS: The 3 children with arthrogryposis and vocal fold dysfunction had laryngoscopy-confirmed vocal fold immobility or significant restriction of motion. The intraoperative L-EMG tracings obtained from all 3 patients demonstrated motor unit action potentials without evidence of denervation. CONCLUSIONS: This series, albeit small, suggests that the vocal fold dysfunction related to arthrogryposis may be attributable to cricoarytenoid joint restriction or poor laryngeal coordination, rather than to nerve paralysis, as originally postulated.

Tremulous arytenoid movements predict severity of glottic stenosis in multiple system atrophy.

To determine whether tremulous arytenoid movements predict the severity of glottic stenosis in patients with multiple system atrophy (MSA), 28 MSA patients and 14 age-matched controls underwent fiberoptic laryngoscopy with video monitoring during wakefulness and under anesthesia induced by intravenous injection of propofol. Presence or absence of tremulous arytenoid movements was recorded during wakefulness. The ratio of glottic stenosis (%), which represents the extent of airway narrowing under anesthesia, was obtained by measuring the inspiratory glottic angle during wakefulness and under anesthesia. The median ratio of glottic stenosis was significantly higher in patients with MSA (57.5%) than in control subjects (0.5%). Tremulous arytenoid movements were characterized by shaking movements of the arytenoid region including the vocal folds, which are most apparent in the arytenoid cartilage. In this study, tremulous arytenoid movements were observed in 18 (64.2%) of 28 patients with MSA, who displayed a significantly higher median ratio of glottic stenosis (71.2%) than other patients (34.9%). None of the control subjects exhibited tremulous arytenoid movements. A clear correlation existed between the ratio of glottic stenosis and disease duration. Our observations indicate that tremulous arytenoid movements are a marker of the severity of glottic stenosis, which confers an increased risk of upper airway obstruction in patients with MSA.

Exercising videoendoscopic evaluation of 45 horses with respiratory noise and/or poor performance after laryngoplasty.

OBJECTIVE: To (1) assess upper airway function by videoendoscopy in horses performing poorly after laryngoplasty and (2) establish whether dynamic collapse of the left arytenoid can be predicted by the degree of resting postsurgical abduction. STUDY DESIGN: Case series. ANIMALS: Horses that had left laryngoplasty (n=45). METHODS: Medical records (June 1993-December 2007) of horses evaluated for abnormal respiratory noise and/or poor performance after laryngoplasty were reviewed. Horses with video recordings of resting and exercising upper airway endoscopy were included and postsurgical abduction categorized. Horses with immediate postoperative endoscopy recordings were also evaluated and postsurgical abduction categorized. Relationships between resting postsurgical abduction and historical information with exercising endoscopic findings were examined. RESULTS: Dynamic collapse of the left arytenoid cartilage was probable in horses with no postsurgical abduction and could not be predicted in horses with grade 3 or 4 postsurgical abduction. Respiratory noise was associated with upper airway obstruction but was not specific for arytenoid collapse. Most horses with a left vocal fold had billowing of the fold during exercise. Other forms of dynamic collapse involved the right vocal fold, aryepiglottic folds, corniculate process of left arytenoid cartilage, dorsal displacement of soft palate, and pharyngeal collapse. Complex obstructions were observed in most examinations and in all horses with exercising collapse of the left arytenoid cartilage. CONCLUSIONS: There was no relationship between exercising collapse of the left arytenoid cartilage and grade 3 or 4 postsurgical abduction but was likely in horses with no abduction.

Regularity of voice recovery and arytenoid motion after closed reduction in patients with arytenoid dislocation: a self-controlled clinical study.

Background: Closed reduction is an effective treatment for arytenoid dislocation. The treatment is usually given more than once to obtain normal voice. However, when to perform the next closed reduction remains controversial.Objective: This study aimed to observe the regularity of the voice recovery and the arytenoid motion in patients with arytenoid dislocation after closed reduction.Material and methods: Thirty-one patients were recruited from September 2017 to April 2019. Results of their clinical data were reviewed retrospectively.Results: Among the thirty-one patients, their VHI scores, F0, jitter%, shimmer%, glottal-to-noise excitation %(GNE), maximum phonation time (MPT) and GRBAS Scale (G, R, B, A) improved significantly (p < .05), but there was no statistically significant difference for GRBAS Scale (S) (p>.05). The duration between last closed reduction and the restoring normal voice ranged from 1-8 days, with a mean of 4.65 ± 0.57 days, at the same time the glottis was completely closed.Conclusions and significance: Closed reduction for patients with arytenoid dislocation is an effective procedure. A time window between 4.08th and 5.22th day (at a confidence level of 95%) after the last closed reduction was identified to be critical for voice recovery.

Characteristics of the Voice Handicap Index for Patients With Unilateral Vocal Fold Paralysis Who Underwent Arytenoid Adduction.

PURPOSE: This study was performed to evaluate the characteristics of the Voice Handicap Index (VHI), a self-assessment measure, for patients with unilateral vocal fold paralysis (UVFP) who underwent arytenoid adduction (AA), in comparison with postoperative vocal function examinations. METHODS: A retrospective chart review was conducted for patients who underwent AA at Tohoku University Hospital during the period between 2014 and 2017. VHI was compared before and after surgery; moreover, correlations were assessed between the VHI and other voice measurements, including perceptual assessment of voice, as well as aerodynamic and acoustic measures. Factors involved in the VHI score were explored by multivariate analysis. RESULTS: Forty-three UVFP patients (28 males, age 32-81 years; 15 females, age 34-80 years) were enrolled in the study; the average age of all patients was 61.5 years (32-81 years). Among the enrolled patients, 33 (76.7%) left and 10 (23.3%) right vocal folds were impaired. After surgery, nearly all of the patients exhibited significantly improved VHI score; each of the three subscales (functional, physical, and emotional) was also improved. The postoperative VHI correlated mildly with several values of the other voice measurements, with the exception of the mean flow rate. Multivariate analysis showed that the sole variable associated with postoperative VHI score was preoperative VHI. CONCLUSIONS: The postoperative VHI likely reflects improvement in the voices of the patients with UVFP. Although there were weak correlations with other voice measures, postoperative VHI is a relatively independent measurement parameter for patients with UVFP who underwent AA.

Surgical Impact of the Montgomery Implant System on Arytenoid Cartilage and the Paralyzed Vocal Fold.

OBJECTIVES/HYPOTHESIS: Medialization thyroplasty (MT) has become a prominent method for treating glottal insufficiency. This study aimed to visualize the biomechanical influence of a medialization implant on arytenoid cartilage, particularly on the length and level of paralyzation in the vocal fold, in patients with unilateral vocal fold paralysis. STUDY DESIGN: Prospective study. METHODS: We recruited 15 patients (10 men, 5 women) with unilateral vocal fold paralysis that underwent MT with a Montgomery® thyroplasty implant. We performed high-resolution computed tomography of the arytenoid cartilage before and after MT and analyzed the three-dimensional images. To visualize the movement of the arytenoid and to measure the lengthening of the vocal fold, we superimposed pre- and postoperative 3D images with MIMICS software. RESULTS: On the affected side, the implant pushed the arytenoid backwards. In addition, the vocal process of the arytenoid was inwardly rotated. These movements resulted in an elongated, augmented vocal fold on the affected side. CONCLUSION: MT led to an elongated, medialized vocal fold on the treated side. After the intervention, the vocal folds on both sides were the same length in the phonatory position.

Effect of poll flexion and dynamic laryngeal collapse on tracheal pressure in Norwegian Coldblooded Trotter racehorses.

REASON FOR PERFORMING STUDY: Dynamic laryngeal collapse (DLC) associated with poll flexion is a newly diagnosed upper respiratory tract obstructive disorder that causes poor racing performance. OBJECTIVES: To determine if Norwegian Coldblooded Trotters (NCTs) affected with DLC associated with poll flexion differ from normal, elite NCTs based on simple airway mechanics measurements. METHODS: Five normal elite NCTs and 6 NCTs diagnosed previously with DLC underwent treadmill videoendoscopy while tracheal pressures were measured continuously. Alternating head positions were used such that horses were exercised with free head carriage and induced poll flexion at heart rates >200 beats/min. RESULTS: Peak inspiratory tracheal pressures were significantly more negative for horses with DLC compared to the elite horses. This difference was only significant during the exercise phases when the poll region was flexed, P = 0.0015. Head position significantly affected peak inspiratory pressure for both elite and affected horses, P < 0.0001. CONCLUSIONS AND CLINICAL RELEVANCE: Induced poll flexion significantly affected peak inspiratory pressure (PIP) in all horses; however, PIPs were significantly more negative in those affected with DLC. Based upon the tracheal pressure measurements recorded in this study, DLC in NCTs is a severe obstructive upper respiratory tract disorder that is induced by poll flexion.

Characterization of arytenoid vertical displacement in unilateral vocal fold paralysis by three-dimensional computed tomography.

The paralyzed arytenoid is not immobile and is subjected to passive movement during phonation. If anatomical changes during inspiration and phonation are compared by three-dimensional computed tomography (3D CT), it is possible to observe vertical movement of the paralyzed arytenoid. Our aim was to use 3D CT to examine the characteristics of 3D arytenoid movement in unilateral vocal fold paralysis (UVFP). This is a prospective study. A total of 61 patients (18 females and 43 males) with UVFP who had undergone 3D CT imaging between April 2005 and January 2007 were included. Cricoid and arytenoid cartilage was imaged by 3D CT. We detected the movements of the paralyzed side when comparing inspiration and phonation. The degree of cranial displacement of the paralyzed arytenoids was classified into three grades (I for mild to III for severe). The mean flow rate (MFR) was calculated for each grade. By comparing the MFR of each grade with the normal control group, we determined whether cases would worsen according to grade. Passive gliding movement of the paralyzed arytenoids was found in 90.7% of cases. In all cases, the paralyzed arytenoids were displaced cranially compared to the unaffected side. MFR worsened significantly as the grade became more severe. We believe that the passive gliding movements observed when comparing inspiration and phonation are characteristic of paralysis. Even in mild cases, the paralyzed arytenoids are passively displaced cranially during phonation, and the degree of this displacement is one indicator that can be used to evaluate the severity of UVFP.

Reliability and Construct Validity of the Penetration-Aspiration Scale for Quantifying Pediatric Outcomes after Interarytenoid Augmentation.

OBJECTIVE: To assess the reliability and construct validity of the Penetration-Aspiration Scale in children. STUDY DESIGN: This was a retrospective cohort study of pre- and postoperative video modified barium swallow studies from children who underwent interarytenoid injection augmentation for unexplained persistent pharyngeal dysphagia. Two pediatric speech and language pathologists reviewed each study twice in a blinded and randomized fashion. SETTING: Tertiary academic pediatric hospital. SUBJECTS AND METHODS: Thirty children were identified with adequate pre- and postoperative modified barium swallow studies within 4 weeks of intervention. Children were separated into clinical outcome groups based on ability to advance to thinner diet consistencies postoperatively. Construct validity was assessed with a mixed linear model to test the hypothesis that only the clinically improved group would receive better Penetration-Aspiration Scale scores after surgery. Reliability was assessed by calculating chance-corrected agreement between raters (interrater) and raters' repeat evaluations (intrarater). RESULTS: Inter- and intrarater reliabilities (Cohen's κ) were both excellent. Results of the mixed model revealed a significant interaction between outcome group and pre- and postoperative time interval. As hypothesized, this involved a significant improvement in Penetration-Aspiration Scale score only in the improved group. CONCLUSIONS: These findings suggest that the Penetration-Aspiration Scale is a reliable and valid measure of clinical response to interarytenoid injection augmentation in children.

Detection of Arytenoid Dislocation Using Pixel-valued Cuneiform Movement.

OBJECTIVES: This study aims to assess utility of pixel-valued movement software in detecting arytenoid dislocation preoperatively. STUDY DESIGN: This is a retrospective analysis. METHODS: Twenty-seven patients diagnosed with unilateral arytenoid dislocation were included. Diagnosis of arytenoid dislocation was confirmed by lack of vocal fold paralysis on preoperative laryngeal electromyography and by intraoperative findings of cricoarytenoid dislocation. A region-tracking software algorithm developed by Zhuang et al was used to analyze 27 preoperative endoscopic videos of patients diagnosed with arytenoid dislocation. Vector analysis measuring cuneiform movement during inspiration was used as an indirect measure of arytenoid movement. Values were normalized using vocal fold length. Two raters blinded to diagnosis of arytenoid dislocation measured vocal fold length and cuneiform movement on both the dislocated and the nondislocated sides. RESULTS: A Wilcoxon signed-rank test indicated that the mean pixel-valued cuneiform movement and standard deviation (SD) were greater for nondislocated (159.24, SD = 73.35) than for dislocated (92.49, SD = 72.11) arytenoids (Z = 3.29, P = 0.001). The interrater correlation coefficient was 0.87 for the dislocated side and 0.75 for the nondislocated side. The intrarater correlation coefficient was 0.87 for the dislocated side and 0.91 for the nondislocated side. The receiver operating characteristic curve revealed an area under the curve between 0.76 and 0.83 (95% confidence interval 0.63-0.90). Analysis by the first and second raters revealed misdiagnosis of laterality of arytenoid dislocation in four and six patients, respectively. CONCLUSIONS: The software program developed by Zhuang et al provides a high-degree of precision, with good interrater and intrarater correlation coefficients. However, high rates of misdiagnosis of arytenoid dislocation and the laborious analysis process using this software program make it of limited utility as a clinical diagnostic tool in its present state.

Quantitative Measurement of the Three-dimensional Structure of the Vocal Folds and Its Application in Identifying the Type of Cricoarytenoid Joint Dislocation.

OBJECTIVE: The objective of this study was to quantitatively measure the three-dimensional (3D) structure of the vocal folds in normal subjects and in patients with different types of cricoarytenoid dislocation. We will analyze differences in parameters between the groups and also determine if any morphologic parameters possess utility in distinguishing the type and the degree of cricoarytenoid dislocation. STUDY DESIGN: This retrospective study was conducted using university hospital data. METHODS: Subjects' larynges were scanned using dual-source computed tomography (CT). The normal subjects were divided into deep-inhalation and phonation groups, and patients with cricoarytenoid joint dislocation were divided into anterior-dislocation and posterior-dislocation groups. Membranous vocal fold length and width were measured directly on the thin-section CT images. Vocal fold and airway 3D models were constructed using Mimics software and used in combination to measure vocal fold thickness, subglottal convergence angle, and oblique angle of the vocal folds. RESULTS: The phonation group displayed a greater vocal fold width, greater oblique angle, thinner vocal folds, and a smaller subglottal convergence angle than those of the deep-inhalation group (P < 0.05). The anterior-dislocation group displayed a smaller oblique angle and subglottal convergence angle than the posterior-dislocation group (P < 0.05). CONCLUSIONS: The 3D structure of the vocal folds during deep inhalation and phonation can be accurately measured using dual-source CT and laryngeal 3D reconstruction. As the anterior-dislocation group yielded negative values for the oblique angle and the posterior-dislocation group yielded positive values, the oblique angle of the vocal folds may possess utility for distinguishing the type and for quantitatively determining the degree of cricoarytenoid dislocation.

Cricoarytenoid Joint Ankylosis: Classification and Transoral Laser Microsurgical Treatment.

OBJECTIVE: This study aimed to describe a graduated approach for effective transoral mobilization of cricoarytenoid joint ankylosis (CJA) in the context of the Bogdasarian system of classifying posterior glottic web-based stenosis (PGWS). STUDY DESIGN: This is a retrospective cohort study through data from medical records and operative notes. A consecutive series of 23 patients who underwent reconstructive transoral laser microsurgery for PGWS with a significant degree of CJA (Bogdasarian grade III-IV) was included in the study. METHODS: Techniques necessary to remobilize their cricoarytenoid joints were reviewed in the context of the extent of scar tissue found. RESULTS: Arytenoids with CJA were successfully mobilized by resection of the fused portion of the cricoid and arytenoid cartilages achieving respiratory improvements as well as decannulation of tracheostomy-dependent patients. The majority (83%) of patient's voices improved. All patients tolerated a full diet after the procedures. Cases with Bogdasarian grade III PGWS with minor unilateral fixation should be classified as IIIa. If the fixation is severe, the case should be classified as a grade IIIb. Grade IVa would indicate that both sides were mildly to moderately ankylosed, and grade IVb involves ankylosis of both joints with subtotal or complete fusion of at least one; it presents the greatest surgical challenge. CONCLUSION: We provided effective transoral techniques for the re-mobilization of cricoarytenoid joint, along with a classification of CJA that aims to standardize the severity of disease in the context of the existing and widely accepted Bogdasarian scale.

Clinical trials using a telemetric endoscope for use during over-ground exercise: a preliminary study.

Dynamic collapse of the upper respiratory tract (URT) is a common cause of poor performance in horses. These conditions occur predominantly during strenuous exercise when the URT is unable to maintain dilation in the face of high inspiratory pressures. In most cases, these disorders cannot be accurately diagnosed during a resting endoscopic examination. To date, a definitive diagnosis of dynamic URT obstructions has been possible only by performing an endoscopic examination during high-speed treadmill exercise. However, recent technological advances now enable URT endoscopy to be performed while the horse is exercising in its normal environment.

Surgical and conservative management of bilateral dynamic laryngeal collapse associated with poll flexion in harness race horses.

OBJECTIVE: To test the hypothesis that in bilateral dynamic laryngeal collapse associated with poll flexion, vocal fold collapse (VFC) is the initial abnormal event that induces further laryngeal collapse, and that racing performance would therefore be substantially improved after bilateral ventriculocordectomy in affected individuals. STUDY DESIGN: Retrospective study. ANIMALS: Twenty-six horses. METHODS: Medical records (1998-2006) of harness racehorses admitted for high-speed treadmill videoendoscopy (HSTV) that had bilateral dynamic laryngeal collapse associated with poll flexion were reviewed. Race records, owner interviews, and follow-up HSTV were used to evaluate outcome after either surgical treatment including bilateral ventriculocordectomy or conservative management. RESULTS: Bilateral dynamic laryngeal collapse, defined as bilateral VFC with concurrent arytenoid cartilage collapse (ACC), was identified in 26 horses. Norwegian Coldblooded Trotters (NCT) were overrepresented. Sixteen horses had surgical treatment and 10 were treated conservatively. Return to racing and racing performance was not improved within or between groups after the treatment. On follow-up HSTV of 6 surgically treated horses, there was no residual soft tissue collapse in the ventral portion of the rima glottidis; however, ACC and other abnormalities were still evident. CONCLUSION: Bilateral ventriculocordectomy resolved VFC, but failed to stabilize the arytenoid cartilages or to significantly improve racing performance. CLINICAL RELEVANCE: Bilateral dynamic laryngeal collapse associated with poll flexion is a serious performance-limiting upper respiratory tract disorder that is overrepresented in NCT racehorses. Our results suggest that VFC is not the initiating event in this complex obstructive airway disorder for which there is currently no consistently effective treatment.

Assessment of vocal cord movement by ultrasound in the ICU.

PURPOSE: Ultrasound can be used to non-invasively and rapidly examine airway conditions, but vocal cord visualization with the traditional approaches is poor. Our aim was to compare the accuracies of front-side transverse-axis ultrasound (FTU), lateral-side longitudinal-axis ultrasound (LLU), and the combination of both approaches for vocal cord movement disorder diagnoses (e.g., vocal cord paralysis or arytenoid cartilage dislocation). METHODS: We compared FTU, LLU, and the combination of both methods for patients in the intensive care unit (ICU). We used nasal fiber-optic endoscopy to confirm vocal cord injury. RESULTS: Among the 120 patients examined, 24 (20%) had vocal cord paralysis. The visualization rate of vocal cords for FTU was 71.7% (assessable, 86; non-assessable, 34), that for LLU was 88.3% (assessable, 106; non-assessable, 14), and that for the combined approach was 96.7% (assessable, 116; non-assessable, 4). The sensitivities and specificities were 58.3% (14/24) and 75% (72/96) for FTU, 91.7% (22/24) and 87.5% (84/96) for LLU, and 100% (24/24) and 95.8% (92/96) for the combined approach. Visualization rates for LLU were significantly higher than for FTU (P = 0.002); FTU + LLU rates were higher than those for FTU (P = 0.001). The difference between LLU and FTU + LLU was not statistically significant (P = 0.025). CONCLUSION: LLU can be used to evaluate arytenoid cartilage activity in ICUs, and the results are highly correlated with the diagnosis of nasal fiber-optic endoscopy. The combination of FTU and LLU shows promise as a rapid primary screening method for vocal cord injury.

Laryngopharyngeal abnormalities in hospitalized patients with dysphagia.

OBJECTIVES: To determine the prevalence of laryngopharyngeal (LP) abnormalities in hospitalized patients with dysphagia referred for flexible endoscopic evaluation of swallowing (FEES). STUDY DESIGN: Retrospective, blinded review by two otolaryngologists of 100 consecutive FEES studies performed and video-recorded by a speech-language pathologist (SLP). METHODS: Two otolaryngologists reviewed videos of 100 consecutive FEES studies on hospitalized patients with dysphagia for the presence of abnormal LP findings. RESULTS: Sixty-one male and 38 female patients comprised the hospital dysphagia cohort. The mean age was 62. One subject could not be evaluated because of the severity of the retained secretions, leaving 99 subjects in the cohort. Seventy-six percent had been previously intubated, with a mean intubation duration of 13 days. The overall prevalence of abnormal LP findings was 79%. Forty-five percent of the patients presented with two or more findings, which included arytenoid edema (33%), granuloma (31%), vocal fold paresis (24%), mucosal lesions (17%), vocal fold bowing (14%), diffuse edema (11%), airway stenosis (3%), and ulcer (6%). There was a significant difference in LP findings between those individuals who had or had not been intubated. CONCLUSIONS: Hospitalized patients with dysphagia are at high risk for LP abnormalities, particularly if they have been intubated, and may benefit from either 1) an initial joint examination by the SLP and otolaryngologist or 2) an otolaryngologist's review of the recorded examination conducted by the SLP. Such otolaryngology involvement could identify airway stenosis patients at an earlier stage, initiate granuloma treatment sooner, enable earlier biopsy of unexpected lesions, and allow follow-up of mucosal and neuromuscular findings that do not respond to medical management.