[Polypositional transcutaneous ultrasound assessment of vocal folds mobility. Ultrasonographic sign of laryngeal dysfunction]. / Polipozitsionnoe ul'trazvukovoe issledovanie golosovykh skladok v diagnostike narushenii podvizhnosti gortani.

Fiberoptic laryngoscopy is a standard procedure for evaluation of vocal folds immobility. However, this method is invasive, requires special qualifications and technical equipment, which limits its routine use. Therefore, in daily practice, the vast majority of laryngoscopy are performed by an indirect way, the accuracy of which depends on the specialist experience and the patient compliance. On the other hand, a large number of patients require for a convenient, non-invasive and inexpensive approach to assess the vocal folds mobility. The transcutaneous laryngeal ultrasonography can be such a method. However, the disadvantage of this technique is low informative value. OBJECTIVE: To increase the effectiveness of the diagnosis of laryngeal dysfunction using transcutaneous laryngeal ultrasonography. MATERIAL AND METHODS: Patients underwent laryngeal ultrasonography and videolaryngoscopy before and after thyroid or parathyroid surgery. Ultrasound was performed polypositionally in the transverse and oblique planes. Functional tests with breathing and breath holding were used. Qualitative (the smile or flying bird signs, the vertical closing line of the vocal folds, synchronicity and symmetry movement of the arytenoid cartilages) and quantitative (the length contraction of the vocal cord, the rotation angle of the arytenoid cartilage) ultrasonic parameters determin the normal vocal folds mobility. RESULTS: 996 patients were included in the study. Vocal folds paresis was detected in 106 (10.6%) patients. In 72 (7.2%) cases partial impaired mobility of the vocal folds (laryngeal dyskinesia) were detected. The echographic patterns of these patients were analyzed. Qualitative ultrasound signs of laryngeal dysfunction were identified: a crooked smile or falling bird signs, a closing line deformation of the vocal folds, an arytenoid immobility. Quantitative ultrasound signs included: a decrease in the length contraction of the vocal cord and a reduction of rotation angle of the arytenoid cartilage. Unilateral laryngeal paresis was diagnosed in 101 (10.1%) patients. In unilateral disorders the rotation angle of the arytenoid on the affected side was 0-14° and the length contraction of the vocal cord was 0-1.8 mm. A crooked smile or falling bird signs, a closing line deformation of the vocal folds and immobility of the arytenoid cartilages were also determined. In 5 (0.5%) cases bilateral laryngeal paresis was revealed, in which on both sides the rotation angles of the arytenoid were 0-14°, and the length contraction of the vocal cords was 0-1.8 mm. At the same time there was no a smile or flying bird signs and a closing line of the vocal folds. Laryngeal dyskinesia was characterized by a crooked smile or falling bird signs and a closing line deformation of the vocal folds. At the same time, partial mobility of the arytenoid cartilage was noted in comparison with the contralateral side (there was a difference in the rotation angle of the arytenoid between the right and left sides of 15 ° or more degrees). CONCLUSION: The sensitivity and specificity polypositional ultrasound of the vocal folds in women were 100% and 99.8%, in men - 85.7% and 99.2%, respectively.

Pre- and intraoperative acoustic and functional assessment of the novel APrevent® VOIS implant during routine medialization thyroplasty.

PURPOSE: Persistent unilateral vocal fold paralysis (UFVP) with glottal insufficiency often requires type I medialization thyroplasty (MT). Previous implants cannot be adjusted postoperatively if necessary. The newly developed APrevent® VOIS implant (VOIS) can provide postoperative re-adjustment to avoid revision MT. The objective of this pilot study is to evaluate the VOIS intraoperatively concerning voice improvement, surgical feasibility and device handling. METHODS: During routine MT, VOIS was applied short time in eight patients before the regular implantation of the Titanium Vocal Fold Medialization Implant (TVFMI™). In all patients, perceptual voice sound analysis using R(oughness)-B(reathiness)-H(oarseness)-scale, measurement of M(aximum)-P(honation)-T(ime) and glottal closure in videolaryngoscopy were performed before and after implanting VOIS/TVFMI™. Acoustic analyses of voice recordings were performed using freeware praat. Surgical feasibility, operative handling and device fitting of VOIS and TVFMI™ were assessed by the surgeon using V(isual)-A(nalog)-S(cale). Data were statistically analyzed with paired t test. RESULT: All patients showed significant improvement of voice sound parameters after VOIS/TVFMI™ implantation. The mean RBH-scale improved from preoperative R = 2.1, B = 2.3, H = 2.5 to R = 0.6, B = 0.3, H = 0.8 after VOIS and R = 0.5, B = 0.3, H = 0.8 after TVFMI™ implantation. The mean MPT increased from preoperative 7.9 to 14.6 s after VOIS and 13.8 s after TVFMI™ implantation. VOIS/TVFMI™ achieved complete glottal closure in 7/8 patients. The satisfaction with intraoperative device fitting and device handling of VOIS was as good as that of TVFMI™. CONCLUSION: The novel APrevent® VOIS implant showed similar intraoperative voice improvement compared to routinely used TVFMI™ without adverse device events and with safe device fitting.

The incidence and recovery rate of idiopathic vocal fold paralysis: a population-based study.

PURPOSE: To determine the incidence and spontaneous recovery rate of idiopathic vocal fold paralysis (IVFP) and paresis (IVFp), and the impact of steroid treatment on rates of recovery. METHODS: This retrospective cohort study included all patients with IVFP or IVFp within a large integrated health-care system between January 1, 2008 and December 31, 2014. Patient demographics and clinical characteristics, including time to diagnosis, spontaneous recovery status, time to recovery, and treatment, were examined. RESULTS: A total of 264 patients were identified, 183 (69.3%) with IVFP and 81 (30.7%) with IVFp. Nearly all cases (96.6%) were unilateral and 89.8% of patients were over the age of 45. The combined (IVFP and IVFp) 7-year mean incidence was 1.04 cases per 100,000 persons each year with the highest 7-year mean annual incidence in white patients (1.60 per 100,000). The total rate of spontaneous recovery was 29.5%, where 21.2% had endoscopic evidence of resolution and 8.3% had clinical improvement in their voice without endoscopic confirmation. The median time to symptom resolution was 4.0 months. Use of steroids was not linked with spontaneous recovery in multivariable analyses. CONCLUSION: The annual incidence of VFP (IVFP and IVFp) was 1.04 cases per 100,000 persons, with spontaneous recovery occurring in nearly a third of patients, regardless of steroid use.

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

PURPOSE: Laryngeal 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. METHODS: For 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. RESULT: When 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. CONCLUSION: A 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.

Risk factors and prognosis of voice disorders after surgical treatment of thyroid and parathyroid diseases. / Faktory riska i prognozirovanie narushenii golosa posle khirurgicheskogo lecheniia zabolevanii shchitovidnoi i okoloshchitovidnykh zhelez.

AIM: To analyze risk factors and prognosis of voice disorders after surgical treatment of thyroid and parathyroid diseases. MATERIAL AND METHODS: There were 1272 patients who were operated in the endocrine surgery department for the period from January 1, 2016 to April 30, 2017. We studied the incidence of VF paresis, VF paralysis, and persistent dysphonia as clinical outcomes. Potential risk factors have to be analyzed were sex and age of patients, BMI, diagnosis, surgical technique, thyroid volume, experience of the surgeon and assistant, use of intraoperative neuromonitoring, etc. RESULTS: Significant relationships of risk factors with various complications of thyroid surgery were found. In logistic regression analysis, the independent predictors of complications were the following: 1) for VF paresis - extent of surgery and thyroid volume; 2) for VF paralysis - sex, extent of surgery and thyroid volume; 3) for persistent postoperative dysphonia - age and thyroid volume. CONCLUSION: The correlation of various risk factors with development of VF paresis, VF paralysis and persistent dysphonia were identified in patients undergoing thyroid and parathyroid surgery.

Vocal fold paresis: Medical specialists' opinions on standard diagnostics and laryngeal findings.

PURPOSE: There is still no clear consensus on the diagnostic value of specific laryngeal findings in patients with suspected vocal fold paresis (VFP). The aim of the study was to establish expert opinion on criteria for the diagnosis of VFP in Europe. METHODS: A cross-sectional survey using the questionnaire introduced by Wu and Sulica for US American experts was addressed to laryngeal experts in Germany, Austria, and Switzerland and in a second survey wave to members of the European Laryngological Society. RESULTS: 100 respondents returned survey 1 (response rate 47.2%). 26% worked at a university department. 28% regularly used laryngeal electromyography (LEMG). A pathologic test results in LEMG was considered to have the strongest positive predictive value for VFP (79 ± 23%), followed by a decreased vocal fold abduction (70 ± 29%), decreased vocal fold adduction (61 ± 34%), and atrophy of the hemilarynx (61 ± 31%). The multivariate analysis showed the predictive value of LEMG was estimated lower by respondents from non-university hospital (ß = - 16.33; confidence interval (CI) = - 25.63 to - 7.02; p = 0.001) and higher in hospitals with higher frequency of VFP patients per months (ß = 1.57; CI = - 0.98 to 2.16; p < 0.0001). 30 ELS members returned survey 2 (response rate, 8.4%). Their answers were not significantly different to survey 1. CONCLUSIONS: The laryngology experts in Europe rely on LEMG for diagnosis of VFP like the US American experts, but paradoxically only a minority uses LEMG frequently. Next to LEMG, motion abnormities were considered to have the best predictive value for the diagnosis of VFP.

The current state of intermittent intraoperative neural monitoring for prevention of recurrent laryngeal nerve injury during thyroidectomy: a PRISMA-compliant systematic review of overlapping meta-analyses.

PURPOSE: Recurrent laryngeal nerve (RLN) injury is one of the most common and detrimental complications following thyroidectomy. Intermittent intraoperative nerve monitoring (I-IONM) has been proposed to reduce prevalence of RLN injury following thyroidectomy and has gained increasing acceptance in recent years. METHODS: A comprehensive database search was performed, and data from eligible meta-analyses meeting the inclusion criteria were extracted. Transient, permanent, and overall RLN injuries were the primary outcome measures. Quality assessment via AMSTAR, heterogeneity appraisal, and selection of best evidence was performed via a Jadad algorithm. RESULTS: Eight meta-analyses met the inclusion criteria. Meta-analyses included between 6 and 23 original studies each. Via utilization of the Jadad algorithm, the selection of best evidence resulted in choosing of Pisanu et al. (Surg Res 188:152-161, 2014). Five out of eight meta-analyses demonstrated non-significant (p > 0.05) RLN injury reduction with the use of I-IONM versus nerve visualization alone. CONCLUSIONS: To date, I-IONM has not achieved a significant level of RLN injury reduction as shown by the meta-analysis conducted by Pisanu et al. (Surg Res 188:152-161, 2014). However, most recent developments of IONM technology including continuous vagal IONM and concept of staged thyroidectomy in case of loss of signal on the first side in order to prevent bilateral RLN injury may provide additional benefits which were out of the scope of this study and need to be assessed in further prospective multicenter trials.

Nomenclature proposal to describe vocal fold motion impairment.

The terms used to describe vocal fold motion impairment are confusing and not standardized. This results in a failure to communicate accurately and to major limitations of interpreting research studies involving vocal fold impairment. We propose standard nomenclature for reporting vocal fold impairment. Overarching terms of vocal fold immobility and hypomobility are rigorously defined. This includes assessment techniques and inclusion and exclusion criteria for determining vocal fold immobility and hypomobility. In addition, criteria for use of the following terms have been outlined in detail: vocal fold paralysis, vocal fold paresis, vocal fold immobility/hypomobility associated with mechanical impairment of the crico-arytenoid joint and vocal fold immobility/hypomobility related to laryngeal malignant disease. This represents the first rigorously defined vocal fold motion impairment nomenclature system. This provides detailed definitions to the terms vocal fold paralysis and vocal fold paresis.

Current Knowledge on the Use of Neuromonitoring in Thyroid Surgery.

Thyroid surgery rates have tripled over the past three decades, making it one of the most frequently performed procedures within general surgery. Thyroid surgery is associated with the possibility of serious postoperative complications which have a significant impact on the patient's quality of life. Recurrent laryngeal nerve (RLN) palsy and external branch of the superior laryngeal nerve (EBSLN) palsy are, next to hypoparathyroidism and postoperative bleeding, some of the most common complications. The introduction of neuromonitoring into thyroid surgery, which enabled both the confirmation of anatomical integrity and the assessment of laryngeal nerve function, was a milestone that began a new era in thyroid surgery. The International Neural Monitoring Study Group has produced a standardization of the technique of RLN and EBSLN monitoring during thyroid and parathyroid surgery, which in turn increased the prevalence of neural monitoring during thyroidectomy. The current status of IONM and the benefits of its use have been presented in this publication.

Effects of Thyroarytenoid Activation Induced Vibratory Asymmetry on Voice Acoustics and Perception.

INTRODUCTION: Asymmetry of vocal fold (VF) vibration is common in patients with voice complaints and also observed in 10% of normophonic individuals. Although thyroarytenoid (TA) muscle activation plays a crucial role in regulating VF vibration, how TA activation asymmetry relates to voice acoustics and perception is unclear. We evaluated the relationship between TA activation asymmetry and the resulting acoustics and perception. METHODS: An in vivo canine model of phonation was used to create symmetric and increasingly asymmetric VF vibratory conditions via graded stimulation of bilateral TA muscles. Naïve listeners (n = 89) rated the perceptual quality of 100 unique voice samples using a visual sort-and-rate task. For each phonatory condition, cepstral peak prominence (CPP), harmonic amplitude (H1-H2), and root-mean-square (RMS) energy of the voice were measured. The relationships between these metrics, vibratory asymmetry, and perceptual ratings were evaluated. RESULTS: Increasing levels of TA asymmetry resulted in declining listener preference. Furthermore, only severely asymmetric audio samples were perceptually distinguishable from symmetric and mildly asymmetric conditions. CPP was negatively correlated with TA asymmetry: voices produced with larger degrees of asymmetry were associated with lower CPP values. Listeners preferred audio samples with higher values of CPP, high RMS energy, and lower H1-H2 (less breathy). CONCLUSION: Listeners are sensitive to changes in voice acoustics related to vibratory asymmetry. Although increasing vibratory asymmetry is correlated with decreased perceptual ratings, mild asymmetries are perceptually tolerated. This study contributes to our understanding of voice production and quality by identifying perceptually salient and clinically meaningful asymmetry. LEVEL OF EVIDENCE: N/A (Basic Science Study) Laryngoscope, 134:1327-1332, 2024.

Positive Predictive Value of Endoscopic Findings to Diagnose Vocal Fold Paresis.

OBJECTIVE: Laryngoscopy corresponding with laryngeal electromyography (LEMG) is essential in diagnosing vocal fold paresis. However, baseline asymmetry or other diseases oftentimes confound the exam, making diagnosis difficult. There is currently no agreed upon endoscopic criteria proven to reliably correlate with LEMG findings. We define a set of endoscopic findings termed "paresis triad" that, when present together, reliably correlate with LEMG. The paresis triad consists of (1) hypocontraction of the weak side of the larynx with increased ventricular show, (2) hypercontraction of the intact side with bulging of the false fold covering the ventricle, and (3) tilting of the interarytenoid cleft to the weak side. METHODS: We performed a retrospective review of patients with laryngeal asymmetry on laryngoscopy. Patients were divided into two groups: those with consistent paresis triad findings across all pitches and intensities, and those without. All patients underwent LEMG by a neurolaryngologist blinded to the laryngoscopic findings. The endoscopies were then rereviewed in a blinded manner by a second laryngologist to assess inter- and intrarater reliability for identification of the triad. RESULTS: Twelve patients met inclusion criteria (age 50 +/-15, 7F:5M). Nine had the paresis triad. Three had an inconsistent triad. All patients with the paresis triad had LEMG findings consistent with neurologic injury on the suspected side. All patients with inconsistent triad findings had normal LEMG. CONCLUSIONS: Our findings suggest the proposed laryngoscopic paresis triad may be useful objective criteria to diagnose paresis without the need for LEMG. Further prospective studies should examine a larger series of patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1712-1716, 2023.

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

OBJECTIVES: 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. STUDY DESIGN: Retrospective. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:866-874, 2023.

Safety of Laryngeal Electromyography and Repetitive Stimulation.

OBJECTIVES: Laryngeal Electromyography (LEMG) is a procedure used to assess electrical signals from laryngeal muscles. It is considered to be the gold standard test for examining vocal fold paresis/paralysis. Repetitive stimulation studies, which usually are performed at the time of LEMG, can aid in assessment of neuromuscular function. Electromyography poses risks to the patient due to the use of electricity and needles. The purpose of this paper was to evaluate the safety of LEMG and discuss the possible complications. METHODS: This was a retrospective review of patients from January 2015 through February 2022. Information from patient charts included age, sex, chief complaint, past medical history, family medical history, medications, social history, strobovideolaryngoscopy results, type of paresis, professional voice user status, presence of pacemaker, laryngeal electromyography and repetitive stimulation study results, and reported complications. Complications were considered to be anything that differed from the norm. Pain was included as a complication. Data were analyzed for relationships and significance. RESULTS: Five hundred patients were included. Eighteen of the 500 (3.6%) experienced complications. Four (2.1%) males and 14 (4.5%) females experienced complications. Nine of the 18 (50%) reported pain after the procedure, 1 (5.56%) had excessive bleeding (controlled with pressure), 5 (27.78%) reported voice changes, and 3 (16.67%) experienced difficulty with completion of the procedure. No patients with pacemakers or patients taking anticoagulants had complications, but repetitive stimulation studies were not performed on patients with pacemakers. CONCLUSIONS: LEMG and repetitive stimulation studies are safe and effective procedures to examine laryngeal muscles. Repetitive stimulation studies are not recommended for patients with pacemakers.

Predicting Airflow from Measures Sensitive to Mid-cord Glottal Gap During the COVID-19 Pandemic.

OBJECTIVES: To determine if trans-laryngeal airflow, important in assessing vocal function in paresis/paralysis and presbylarynges patients with mid-cord glottal gaps, could be predicted by other measures sensitive to mid-cord glottal gap size but with smaller risks of spreading COVID-19, and if any patient factors need consideration. METHODS: Four populations were: unilateral vocal fold paresis/paralysis (UVFP, 148), aging and UVFP (UVFP plus aging, 22), bilateral vocal fold paresis/paralysis without airway obstruction (BVFP, 49), and presbylarynges (66). Five measures were selected from the initial clinic visit: mean airflow from repeated /pi/ syllables, longer of 2 /s/ and 2 /z/ productions, higher of 2 cepstral peak prominence smoothed for vowel /a/ (CPPSa), and Glottal Function Index (GFI). S/Z ratios were computed. Stepwise regression models used 3 measures and 5 patient factors (age, sex, etiology, diagnosis, and potentially impaired power source for voicing) to predict airflow. RESULTS: Log-transformations were required to normalize distributions of airflow and S/Z ratio. The final model revealed age, sex, impaired power source, log-transformed S/Z ratio, and GFI predicted log-transformed airflow (R2 = .275, F[5,278] = 21.1; P < .001). CONCLUSIONS: The amount of variance explained by the model was not high, suggesting adding other predictive variables to the model might increase the variance explained.

Proving the Superiority of Intraoperative Recurrent Laryngeal Nerve Monitoring over Visualization Alone during Thyroidectomy.

Vocal fold paralysis after thyroid surgery is still a dangerous complication that significantly reduces patients' quality of life. Since the intraoperative neuromonitoring (IONM) technique has been introduced and standardized, the most frequently asked question is whether its use has significantly reduced the rate of RLN injury during thyroid surgery compared to visual identification alone (VA). The aim of this study was to attempt to prove the superiority of IONM over VA of the RLN during thyroid surgery in the prevention of vocal fold paralysis, taking into account risk factors for complications. The medical records of 711 patients (1265 recurrent laryngeal nerves at risk of injury) were analyzed retrospectively: in 257 patients/469 RLNs at risk, thyroid surgery was performed with IONM; in 454 patients/796 RLNs at risk, surgery was performed with VA. The statistical analysis showed that in the group of patients with IONM only one risk factor-the surgeon's experience-proved statistically significant (OR = 3.27; p = 0.0478) regarding the overall risk of vocal fold palsy. In the group of patients where only visualization was used, 5 of the 12 factors analyzed were statistically significant: retrosternal goiter (OR = 2.23; p = 0.041); total thyroid volume (OR = 2.30; p = 0.0284); clinical diagnosis (OR = 2.5; p = 0.0669); gender (OR = 3.08; p = 0.0054) and risk stratification (OR = 3.30; p = 0.0041). In addition, the cumulative risk, taking into account the simultaneous influence of all 12 factors, was slightly higher in the group of patients in whom only VA was used during the procedure: OR = 1.78. This value was also considerably more statistically significant (p < 0.0001) than that obtained in the group of patients in whom IONM was used: OR = 1.73; p = 0.004. Conclusions: Risk factors for complications in thyroid surgery are not significant for any increase in the rate of vocal fold paralysis as long as surgery is performed with IONM, in contrast to thyroid surgery performed only with VA, thus proving the superiority of IONM over VA for safety.

Bilateral vocal fold paresis and glottal bridge synechia in COVID-19.

Key Clinical Message: Bilateral vocal fold paresis (BVFP) is a rare complication in COVID-19 and should be considered as differential diagnosis in COVID-19-patients presenting with dyspnea and stridor. High-dose intravenous corticosteroids can be useful treating COVID-19-related laryngeal edema and vocal fold paresis. This case shows the complexity of laryngeal complications in COVID-19 requiring surgeries and functional therapies. Abstract: Although COVID-19 is known to affect peripheral as well as cranial nerves, there is a paucity of reports on vocal fold paresis in COVID-19, bilateral vocal fold paresis (BVFP) in particular. We describe a case of BVFP and glottal bridge synechia following COVID-19-pneumonia discussing pathomechanisms and treatment options.

Efficacy of the Grit Scale Score in Predicting Voice Therapy Adherence and Outcomes.

BACKGROUND: Voice therapy generally is considered first-line treatment for dysphonia and vocal fold paresis. It requires a commitment of time, effort and resources; currently, there is no good indicator to identify which patients are good candidates for voice therapy. The Grit scale, developed by psychologist Angela Duckworth, provides a method to quantify perseverance and commitment to long-term goals. OBJECTIVE: We hypothesized that the Grit scale score could correlate with patient adherence to voice therapy and outcomes, by which subjects with higher Grit scale scores demonstrate greater adherence and better outcomes. METHODS: Subjects were categorized into five groups, subjects who (1) were discharged from therapy after successful completion, (2) improved to normal, near-normal, or a level of voice function with which the patients were satisfied, and then stopped attending therapy (3) attended as at least the recommended number of sessions or greater than 8 sessions with some voice improvement (4) failed to improve to a voice function level satisfactory to the patient despite attending voice therapy, (5) failed to attend voice therapy as recommended. Subjects in groups 1-4 were considered adherent to voice therapy, whereas group 5 was considered not adherent. Category 1 was considered the most favorable outcome, whereas Category 5 was considered the least favorable outcome (1 > 2 > 3 > 4 > 5). RESULTS: Eighty-nine subjects are included in the study. The average age of subjects was 44.9 years old, and there was a nearly equal split between male and female subjects. The mean Grit score (48) of the adherent group (categories 1-4) was not significantly different from that of the non-adherent group (47, P = 0.190). Spearman's rho between Grit scale score and the categories (1 > 2 > 3 > 4 > 5) was 0.0674, P = 0.530. CONCLUSION: Neither the analysis by groups nor the Spearman correlation across all categories supported our hypothesis that higher Grit scale scores would be associated with better adherence and outcomes. The failure of the Grit scale score to predict adherence to voice therapy and outcomes emphasizes the need for further research to find a metric that will help predict and improve patient adherence with voice therapy and voice outcomes. Further research is needed to determine why it was unable to be predictive and to confirm or refute our findings.

Induced Paresis for Awake Laryngoscopy Procedures.

This article describes an anesthetic technique that induces temporary adductor vocal fold paresis and dense sensory loss of the posterior glottis. This method allows for improved precision of treatment and patient tolerance during awake office-based laryngeal surgery. Laryngoscope, 133:1673-1675, 2023.

Incidence of Vocal Cord Paralysis in Medullary Thyroid Cancer.

OBJECTIVE: Medullary thyroid cancer (MTC) is a neuroendocrine tumor that comprises 3-5% of all thyroid cancers in the United States. Vocal cord paralysis (VCP) may be due to involvement of the recurrent laryngeal nerve (RLN) preoperatively, or nerve sacrifice during surgery. The purpose of this study was to demonstrate the incidence of VCP in MTC and evaluate whether VCP has an impact on overall survival. METHODS: This was a retrospective chart review of patients with MTC treated at Loyola University Medical Center from 2007 to 2021. Information on demographics, cancer diagnosis and treatment, laboratory data, and survival were collected. RESULTS: A total of 79 patients were included in our study. 47 (59.5%) patients were female. The average age at the time of diagnosis was 51.3 years (SD 13.58). VCP was identified in 13 out of 79 (16.5%) patients. There were 71 patients with at least 1-year follow-up with median (Q1, Q3) years of 7.2 (3.9, 11.0). Those with VCP within 1 year had 7.2 (95% CI: 2.3, 22.7) times the risk of death compared to those without (p < 0.001). CONCLUSION: MTC is a rare thyroid cancer, however, its incidence is on the rise. Our study suggests that the incidence of VCP in these patients appears to be higher than seen in other thyroid malignancies, and VCP is associated with a statistically significant negative impact on survival. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:890-894, 2023.

Does the Severity of Vocal Fold Paresis on Laryngeal Electromyography Correlate With Radiographic Findings on Cross Sectional Imaging?

OBJECTIVES: Unilateral vocal fold paresis or paralysis (UVFP) is a condition for which radiographic evaluation and laryngeal electromyography (LEMG) are valuable to evaluate severity of injury and direct treatment plans. Despite extensive research involving findings suggestive of UVFP with radiographic imaging, no study has attempted to determine which findings suggestive of UVFP on imaging are clinically significant and suggest a need for intervention. The purpose of this study was to evaluate whether the severity of vocal fold paresis/paralysis affects the likelihood of encountering radiographic findings suggestive of UVFP. We also aimed to determine which findings suggestive of UVFP on imaging were clinically significant and were associated with surgical intervention. MATERIALS AND METHODS: A retrospective chart review was conducted of patients who had been diagnosed with unilateral vocal fold paresis or paralysis and had been evaluated by CT scan and/or magnetic resonance imaging and laryngeal electromyography (EMG) between the dates of January 1, 2017 and January 9, 2018. Fisher's exact testing with Monte Carlo Simulation was utilized to determine statistical significance of identified relationships. Univariate analysis was conducted to assess for individual relationships between imaging results and the potential predictor variables. Chi square analysis was conducted with the various categorical variables to assess for any potential relationships to imaging results. Statistical significance was determined utilizing chi square analysis. RESULTS: After data collection, 130 patients were included in the study population. Of the 112 patients with documented MRI results, 17% had a reported imaging abnormality suggestive of true vocal fold paresis or paralysis (VFP). Of the 71 patients with documented CT Neck results, 15.4% had an abnormality potentially concerning for true VFP. The average decrease in recruitment of the right and left SLN was 23.8% and 26.1%, respectively. The average decrease in recruitment of the right and left RLN was 37.3% and 57.78%, respectively. Seventy four percent of patients who exhibited abnormal MRI were found to have isolated SLN weakness, and 21% of patients were found to have a combined SLN and ipsilateral RLN weakness. In patients with abnormal CT scans 45% were found to have isolated SLN weakness, and 35% were found to have a combined SLN and RLN weakness. MRI imaging again failed to display any significant degree of paresis. However, abnormal CT results displayed severe CN X paresis in 36.84% vs 1.96% in normal scans. The chance of an abnormal MRI and CT result was 2.78 and 5.55 times greater, respectively, for each increase in the degree of severity of CN X paresis. When looking at the ability of imaging to predict the chance of a patient undergoing surgery, 34.8% of patients with an abnormal MRI underwent surgery compared to just 14.61% of those with normal scans. For CT scans, 35% of patients with an abnormal scan underwent surgery, compared with only 15.69% with normal imaging. When pooled, over 33% of patients with any abnormal imaging underwent a laryngeal procedure compared to 13% of patients with normal imaging. CONCLUSIONS: There is a relationship between severity of vocal fold paresis found on laryngeal EMG and likelihood of detection on imaging. While CT was more likely to find characteristics of UVFP than MRI, patients who had an abnormal finding on either modality were more likely to undergo surgical intervention. These findings highlight the importance of early referral of patients with abnormal laryngeal imaging to an otolaryngologist for evaluation and possible intervention.