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.

Current opinion on laryngeal electromyography.

PURPOSE: This study evaluates expert opinion on laryngeal electromyography (LEMG). METHODS: A cross-sectional design was used to conduct an online survey of LEMG experts in 2021. They were questioned about the number LEMG performed annually, type of electrodes used, sector worked in, pain during the test, placement of the needle electrodes, interpretation of electrical muscle parameters, diagnosis of neuromuscular injury, prognostic sensitivity in vocal fold paralysis (VFP), laryngeal dystonia, tremor and synkinesis and quantifying LEMG. RESULTS: Thirty-seven professionals answered (23 Spanish and 14 from other countries), with a response rate of 21.56%. All physicians used LEMG. 91.9% had one- or two-years' experience and 56.8% performed 10-40 LEMG per year. 70.3% were otolaryngologists and 27%, neurologists. In 89.1% of cases, a team of electrodiagnostic physician and otolaryngologist performed LEMG. 91.3% of Spanish respondents worked in Public Health, 7.14% of other nationalities; 37.8% in a university department. Bipolar concentric needles electrodes were used by 45.9% and monopolar concentric by 40.5%. 57% professionals considered good patients' tolerance to the test. LEMG sensitivity was regarded as strong, median and interquartile range were 80.0 [60.0;90.0] to diagnose peripheral nerve injuries, less for other levels of lesions, and strong to evaluate prognosis, 70.0 [50.0;80.0]. Respondents believe locate the thyroarytenoid and the cricothyroid muscles with the needle, 80.0 [70.0;90.0], as opposed to 20.0 [0.00;60.0] the posterior cricoarytenoid. The interpretation of the electrical parts of the LEMG was strong, 80.0 [60.0;90.0]. LEMG identify movements disorders, 60.0 [20.0;80.0], and synkinesis, 70.0 [30.0;80.0]. The professionals prefer quantitative LEMG, 90.0 [60.0;90.0]. CONCLUSIONS: The experts surveyed consider LEMG that is well tolerated by patients. The insertional and spontaneous activity, recruitment and waveform morphology can be assessed easily. LEMG is mainly useful in the study of peripheral nerve injuries, and its value in VFP prognosis is considered strong.

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.

[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.

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.

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.

The Relationship Between Vocal Fold Mobility Disorders and Ineffective Esophageal Motility.

OBJECTIVE: Deglutition, speech production, and airway protection are extraordinarily complex, interrelated functions that are coordinated, in large part, by the motor and sensory innervation of CN X. Previous studies assessing the relationship between neurogenic voice disorders and dysphagia have focused on the risk of aspiration due to glottic insufficiency and the association of vocal fold hypomobility (VFH) with systemic neurologic disease. The purpose of this study was to investigate the relationship between VFH disorders and ineffective esophageal motility (IEM). METHODS: Adult voice patients who underwent laryngeal electromyography (LEMG) and dual 24-hour pH impedance with high-resolution manometry (HRM) testing were included in the study. Subjects were assigned to one of two groups based on the presence or absence of moderate-to-severe RLN and/or SLN VFH (Mo-SLNH/RLNH) using results from six muscle LEMG tests. In subjects with Mo-SLNH/RLNH, there was 0-60% muscle recruitment on LEMG, whereas control subjects in the non-Mo-SLNH/RLNH group demonstrated 61-100% muscle recruitment. Analysis of mild-to-severe VFH (80% muscle recruitment or less) was also performed in a similar manner. The prevalence of IEM, defined using Chicago Classification Version 4.0 (CCv4.0), was compared between groups, as were HRM parameters. RESULTS: One hundred sixty-two subjects were included (37.7% male/62.3% female, mean age of 43.88 ± 17.285). No differences in IEM prevalence were found when stratifying for cases of mild-to-severe VFH. However, there was significantly higher percentage of IEM in those with Mo-SLNH/RLNH. Mo-SLNH/RLNH subjects demonstrated higher rates of weak swallows and inefficient swallows, as well as lower IBP and UES residual pressures on HRM. CONCLUSIONS: Patients with Mo-SLNH/RLNH demonstrated a significantly higher prevalence of IEM. Those with mild-to-severe VFH did not. Higher rates of ineffective and weak swallows, and lower IBP and UES residual pressures among Mo-SLNH/RLNH subjects suggest a possible connection between Mo-SLNH/RLNH and IEM disorders. These manometric differences were more prominent with sub-stratification of the Mo-SLNH/RLNH group by IEM. Additional research is advised.

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.

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.

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.

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.

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.

Is there Really a Lump in My Throat? The Incidence and Implication of Vocal fold Abnormalities in Patients Presenting with Globus.

OBJECTIVE: To identify the prevalence of vocal fold abnormalities in patients with a primary complaint of globus sensation. Secondly, to determine the relationship between globus, vocal fold abnormality, and patient-reported quality of life questionnaire score. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review was performed to identify all new patients evaluated at a tertiary academic care laryngology practice between January 2018 and December 2018 presenting with a chief complaint of globus. Variables of interest include age, gender, laryngeal symptoms, self-reported quality-of-life questionnaire results, and laryngostroboscopy findings. Questionnaires selected for this investigation include the reflux symptom index (RSI), eating assessment tool-10 (EAT-10), and voice handicap index-10 (VHI-10). RESULTS: Two hundred twenty-eight subjects with an average age of 54 ±17 years, were categorized based on one of three laryngostroboscopic findings: absence of vocal fold abnormality, vocal fold paresis/paralysis (motion abnormality), or a vocal fold mass lesion. Fifty percent of patients reporting globus had a normal laryngeal exam, and 50% had a mass lesion or motion abnormality. Twenty five percent had vocal fold motion abnormality (paresis, paralysis, or supraglottic squeeze); 19% had a mass lesion; and 3% had both a lesion and motion abnormality. The average self-reported survey scores were compared among the three groups. Patients with dysphonia had a significantly higher VHI-10 (P = 0.00), and a significantly higher RSI (P =  0.00) than those without dysphonia. Those patients with dysphagia had significantly higher EAT-10 (P = 0.00) and RSI (P = 0.02) scores than those who did not have dysphagia. Patients with vocal fold motion abnormality had significantly higher VHI-10 than those with normal vocal fold mobility (P = 0.02) CONCLUSIONS: Identifying the etiology of globus presents a significant challenge to laryngologists. Data presented here suggest that vocal fold abnormalities may contribute to the sensation of globus and should therefore be considered in the differential when managing these patients.

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

OBJECTIVES/HYPOTHESIS: 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. STUDY DESIGN: Prospective controlled cohort study. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:S1-S12, 2022.

Vocal Fold Paralysis Following COVID-19 Vaccination: Query of VAERS Database.

OBJECTIVE: Vocal fold paresis or paralysis (VFP) may severely affect quality of life due to dysphonia and respiratory distress. As an increasing percentage of the United States population receives the COVID-19 vaccination, the objective of this study is to determine the correlation of COVID-19 postvaccination recurrent laryngeal neuropathy and resulting VFP. METHODS: The Vaccine Adverse Event Reporting System database was queried for patients exhibiting symptoms of VFP following COVID-19 vaccination. Patient demographics and clinical information including presenting symptoms, time of symptom onset, time of diagnosis and laterality. RESULTS: Twenty patients were found to have laryngoscopy confirmed VFP following COVID-19 vaccination. Vaccinations for Pfizer-BioNTech, Moderna, and Janssen were reported. Of those reported, 13 patients were female (65.0%) and seven were male (35.0%), with a mean age of 61.8 years. The most common presenting symptom was a hoarse voice (30.0%). A majority of these cases were unilateral in nature (64.0%). Mean time from vaccination to symptom onset was 12.1 days and mean time from vaccination to diagnosis was 37.6 days. CONCLUSION: For patients presenting with voice or swallowing complaints after receiving the COVID-19 vaccine, prompt evaluation by an otolaryngologist should occur. However, the potential VFP side effect of vaccination is very rarely cited in the literature and largely outweighed by the benefits of vaccination. Further research is needed to delineate the exact pathophysiology of this complication and determine whether a causal relationship exists.

Acute Vocal Fold Paresis and Paralysis After COVID-19 Infection: A Case Series.

OBJECTIVE: Evidence demonstrates neurotropism is a common feature of coronaviruses. In our laryngology clinics we have noted an increase in cases of "idiopathic" vocal fold paralysis and paresis in patients with no history of intubation who are recovering from the novel SARS-Cov-2 coronavirus (COVID-19). This finding is concerning for a post-viral vagal neuropathy (PVVN) as a result of infection with COVID-19. Our objective is to raise the possibility that vocal fold paresis may be an additional neuropathic sequela of infection with COVID-19. METHODS: Retrospective review of patients who tested positive for COVID-19, had no history of intubation as a result of their infection, and subsequently presented with vocal fold paresis between May 2020 and January 2021. Charts were reviewed for demographic information, confirmation of COVID-19 infection, presenting symptoms, laryngoscopy and stroboscopy exam findings, and laryngeal electromyography (LEMG) results. RESULTS: Sixteen patients presented with new-onset dysphonia during and after recovering from a COVID-19 infection and were found to have unilateral or bilateral vocal fold paresis or paralysis. LEMG was performed in 25% of patients and confirmed the diagnosis of neuropathy in these cases. CONCLUSIONS: We believe that COVID-19 can cause a PVVN resulting in abnormal vocal fold mobility. This diagnosis should be included in the constellation of morbidities that can result from COVID-19 as the otolaryngologist can identify this entity through careful history and examination.

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

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