Comparison of the diagnostic and prognostic abilities of flexible laryngoscopy and dynamic digital radiography for vocal cord paralysis: A prospective observational study.

BACKGROUND: Although flexible laryngoscopy (FL) is the reference modality for diagnosing vocal cord paralysis (VCP), FL involves patient discomfort and insertion intolerance. Dynamic digital radiography (DDR) with high spatial and temporal resolution is easier to use and less invasive when evaluating VCP. METHODS: Seventy-eight patients underwent FL and DDR before and after neck surgery. Qualitative and quantitative vocal cord movement (VCM) evaluations were conducted. Patients with postoperative VCP were followed-up regularly. RESULTS: DDR exhibited diagnostic performance with 67% sensitivity and 100% specificity. The cutoff for VCM was 2.4 mm, with DDR exhibiting 100% sensitivity and 78% specificity. All cords with transient VCP had positive VCM at both 3 weeks and 2 months. Additionally, 50% and 75% of cords with permanent VCP had negative VCM at 3 weeks and 2 months, respectively. CONCLUSIONS: DDR is promising for the diagnosis of postoperative VCP and early prediction of permanent postoperative VCP.

Assessment of pre-extubating recurrent laryngeal nerve palsy using ultrasound in postoperative patients with esophageal cancer: a prospective observational study.

PURPOSE: Ultrasound performed after extubation has been suggested to be useful for the diagnosis of recurrent laryngeal nerve (RLN) paralysis. However, the use of ultrasound for this purpose before extubation has not been examined. The aim of this study was to examine the versatility (interrater reliability) and usefulness of ultrasound for evaluating the movement of vocal cords before extubation. METHODS: The subjects were 30 patients who underwent radical surgery for esophageal cancer from August 2020 to December 2021. An experienced examiner performed an ultrasound examination before and after elective extubation on the day after surgery to evaluate RLN paralysis and record videos. Bronchoscopy was then performed to make a definite diagnosis. Three anesthetists blinded to the diagnosis also evaluated the cases using the videos, and the versatility of the examination was determined using a kappa test. RESULTS: The diagnostic accuracies of the examiner and three anesthetists were 76.7%, 50.0%, 53.3%, and 46.7%, respectively, and the kappa coefficients for the examiner with the anesthetists were 0.310, 0.502, and 0.169, respectively. The sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of RLN paralysis by the examiner using ultrasound before extubation were 0.57, 0.95, 0.80, and 0.87, respectively. CONCLUSION: These results indicate a lack of versatility of the ultrasound examination based on the low kappa coefficients. However, with an experienced examiner, ultrasound can serve as a non-invasive examination that can be performed before extubation with high accuracy and specificity for diagnosis of postoperative RLN paralysis.

Diagnostic Accuracy of Laryngeal Ultrasound for Evaluating Vocal Fold Movement Impairment in Children.

PURPOSE: Vocal fold movement impairment (VFMI) secondary to recurrent laryngeal nerve (RLN) injury is a common source of morbidity after pediatric cervical, thoracic, and cardiac procedures. Flexible laryngoscopy (FL) is the gold standard to diagnose VFMI yet can be challenging to perform and/or risks possible clinical decompensation in some children and is an aerosolizing procedure. Laryngeal ultrasound (LUS) is a potential non-invasive alternative, but limited data exists in the pediatric surgical population regarding its efficacy. We aimed to investigate the diagnostic accuracy of LUS compared to FL in evaluating VFMI. METHODS: A prospective, single-center, single-blinded (rater) cohort study was undertaken on perioperative pediatric patients at risk for RLN injury. Patients underwent FL and LUS. Cohen's kappa was used to determine chance-corrected agreement. RESULTS: Between 2021 and 2023, 85 paired evaluations were performed with patients having a median (IQR) age of 10 (4, 42) months and weight of 7.5 (5.4, 13.4) kilograms. The prevalence of VFMI was 27.1%. Absolute agreement between evaluations was 98.8% (kappa 0.97, 95% CI: 0.91-1.00, P < 0.001). The sensitivity and specificity of LUS in detecting VFMI was 95.7% and 100%, yielding a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 98.4% (95% CI: 90-100%). Diagnostic accuracy was 98.8% (95% CI: 93-100%). CONCLUSION: LUS is a highly accurate modality in evaluating VFMI in children. While FL remains the gold standard for diagnosis, LUS offers a low-risk screening modality for children at risk for VFMI such that only those with an abnormal LUS or presence of clinical symptoms discordant with LUS findings should undergo FL. TYPE OF STUDY: Prospective, single-center, single blinded (rater), cohort study. LEVEL OF EVIDENCE: Level II.

Ultrasound Screening After Cardiac Surgery Shows Vocal Fold Impairment and Predicts Aspiration.

INTRODUCTION: Vocal fold motion impairment (VFMI) is a known consequence after high-risk cardiac surgery. We implemented a universal laryngeal ultrasound (LUS) screening protocol for VFMI after the Norwood and aortic arch surgery. We hypothesized that LUS would accurately identify VFMI and predict postoperative aspiration. METHODS: We implemented a screening algorithm with LUS for patients undergoing high-risk cardiac surgery at a tertiary care pediatric hospital. Positively screened patients underwent flexible nasolaryngoscopy (FNL). Patients with an abnormal FNL underwent a video-fluoroscopic swallow study (VFSS). Patient demographics, length of stay, and swallowing outcomes were assessed. Two-tailed chi square and Wilcoxon rank sum tests were used to assess for differences. RESULTS: Sixty-seven patients underwent either Norwood or arch reconstruction over a 16-month period and underwent universal LUS. The average birth weight was 3.24 kg (SD 0.57). Of the 67 patients, VFMI was identified by LUS and 100% confirmed on FNL in 58.21% (n = 39/67) of patients. Aspiration and penetration on VFSS were higher in the group with VFMI as compared with those without VFMI (53.8% vs. 21.4%, p = 0.008). There was no difference in length of stay between patients who did not have a diagnosis of VFMI and those found to have VFMI (41.0 days vs 45.3 days p = 0.73). CONCLUSIONS: Universal LUS screening for patients following high-risk cardiac surgery may lead to earlier identification of postoperative VFMI and aspiration. Recognition of VFMI through this universal screening program could lead to earlier interventions and possibly improved swallowing outcomes. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1939-1944, 2024.

Parálisis bilateral de las cuerdas vocales con obstrucción aguda de la vía aérea y traqueotomía urgente en una paciente con ictus vertebrobasilar agudo / Bilateral vocal cord paralysis with acute airway obstruction and urgent tracheotomy in a patient with an acute vertebrobasilar stroke

Introducción El ictus vertebrobasilar puede suponer un reto diagnóstico. La parálisis bilateral de las cuerdas vocales como manifestación de ictus agudo es muy rara, pero potencialmente mortal, por la posibilidad de obstrucción aguda de la vía aérea. No hay casos descritos de parálisis bilateral de las cuerdas vocales como presentación de ictus agudo de etiología neurológica mixta central y periférica. Caso clínico Mujer de 88 años con disfonía secuelar a parálisis de la cuerda vocal derecha postiroidectomía que presentó un cuadro brusco de vértigo, dismetría y disartria leve (National Institutes of Health Stroke Scale: 2) asociado a hipertensión arterial. La tomografía computarizada cerebral urgente demostró trombosis distal oclusiva de la arteria vertebral izquierda sin isquemia establecida. Por mejoría sintomática con control tensional, no se realizó terapia de revascularización. Cuatro horas después, la paciente desarrolló de forma brusca estridor inspiratorio e insuficiencia respiratoria grave por parálisis bilateral de las cuerdas vocales con obstrucción completa de la vía aérea. Se realizó una traqueotomía urgente con mejoría respiratoria. Una tomografía computarizada cerebral de control a las 24 horas mostró un infarto establecido en el hemicerebelo izquierdo y la región bulbar lateral, congruente con territorio de la arteria cerebelosa posterior inferior izquierda. Conclusión Nuestro caso ilustra la posibilidad de la rara aparición de una parálisis bilateral aguda de las cuerdas vocales en el contexto de un ictus agudo junto con una afectación periférica crónica del nervio recurrente laríngeo. Aunque es excepcional, ejemplifica el potencial riesgo asociado a los ictus vertebrobasilares. Un tratamiento más agresivo de reperfusión podría ser adecuado en estos casos, pese a un déficit inicialmente leve, por la posibilidad de progresar a complicaciones vitales. (AU)

INTRODUCTION Vertebrobasilar stroke can be a diagnostic challenge. Bilateral vocal cord paralysis is very rare as a manifestation of acute stroke, yet it is potentially life-threatening because of the possibility of acute airway obstruction. No cases of bilateral vocal cord paralysis have been reported as a presenting symptom of acute stroke of mixed central and peripheral neurological aetiology. CASE REPORT An 88-year-old woman with dysphonia resulting from paralysis of the right vocal cord following a thyroidectomy presented with sudden onset of vertigo, dysmetria and mild dysarthria (National Institutes of Health Stroke Scale: 2) associated with arterial hypertension. An urgent brain computed tomography (CT) scan evidenced distal occlusive thrombosis of the left vertebral artery without established ischaemia. Due to the improvement of symptoms achieved with control of her blood pressure, revascularisation therapy was not performed. Four hours later, the patient suddenly developed inspiratory stridor and severe respiratory failure due to bilateral vocal cord paralysis with complete airway obstruction. An urgent tracheotomy was performed, which resulted in an improvement in her breathing. A control brain CT scan performed at 24 hours showed established infarction in the left hemicerebellum and lateral medullary region, consistent with the territory of the left posterior inferior cerebellar artery. CONCLUSION. Our case illustrates the possibility of the rare occurrence of acute bilateral vocal cord paralysis in the context of acute stroke in conjunction with chronic peripheral involvement of the recurrent laryngeal nerve. Although exceptional, it exemplifies the potential risk associated with vertebrobasilar strokes. A more aggressive reperfusion therapy may be appropriate in these cases, despite an initially mild deficit, because of the possibility of progression to life-threatening complications. (AU)

[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.

A Prospective Study Evaluating the Feasibility and Accuracy of Post-operative Laryngeal Ultrasonography (LUSG) in Assessment of Vocal Cord Function After Esophagectomy.

BACKGROUND: Vocal cord paresis (VCP) is a serious complication after esophagectomy. Conventional diagnosis of VCP relies on flexible laryngoscopy (FL), which is invasive. Laryngeal ultrasonography (LUSG) is non-invasive and convenient. It has provided accurate VC evaluation after thyroidectomy but it is unclear if it is just as accurate following esophagectomy. This prospective study evaluated the feasibility and accuracy of LUSG in VC assessment on day-1 after esophagectomy. METHODS: Consecutive patients from a tertiary teaching hospital who underwent elective esophagectomy were prospectively recruited. All received pre-operative FL, and post-operative LUSG and FL on Day-1, each performed by a blinded, independent assessor. The primary outcomes were feasibility and accuracy of LUSG in the diagnosis of VCP on Day-1 post-esophagectomy. The accuracy of voice assessment (VA) was analyzed. RESULTS: Twenty-six patients were eligible for analysis. The median age was 70 years (66-73). Majority were male (84.6%). Twenty-five (96.2%) received three-phase esophagectomy. Twenty-four (96%) had same-stage anastomosis at the neck. Three (11.5%) developed temporary and one (3.8%) developed permanent unilateral VCP. Overall VC visualization rate by LUSG was 100%; sensitivity, specificity, positive predictive value, negative predictive value (NPV) and accuracy of LUSG were 75.0%, 100%, 100%, 98.0%, 98.1% respectively, and superior to VA. Combining LUSG with VA findings could pick up all VCPs i.e. improved sensitivity and NPV to 100%. CONCLUSION: LUSG is a highly feasible, accurate and non-invasive method to evaluate VC function early after esophagectomy. Post-operative FL may be avoided in patients with both normal LUSG and voice.

Subject-Specific Modeling of Implant Placement for Type I Thyroplasty Surgery.

Type I thyroplasty is widely used to improve voice production in patients affected by unilateral vocal fold paralysis. Almost two-thirds of laryngologists report using Silastic® implants to medialize the vocal fold, with implant size, shape, and location determined experientially. However, post-surgical complications arising from this procedure (extrusion, migration, resizing) necessitate revision in 4.5-16% of patients. To improve initial surgical outcomes, we have developed a subject-specific modeling tool, PhonoSim, which uses model reconstruction from MRI scans to predict the optimal implantation location. Eleven vocal fold sample sides from eight larynges of New Zealand white rabbits were randomized to two groups: PhonoSim informed (n = 6), and control (no model guidance, n = 5). Larynges were scanned ex vivo in the abducted configuration using a vertical-bore 11.7 T microimaging system, and images were used for subject-specific modeling. The PhonoSim tool simulated vocal fold adduction for multiple implant location placements to evaluate vocal fold adduction at the medial surface. The best implant placement coordinates were output for the 6 samples in the PhonoSim group. Control placements were determined by the same surgeon based on anatomical landmarks. Post-surgical MRI scans were performed for all samples to evaluate medialization in implanted vocal folds. Results show that PhonoSim-guided implantation achieved higher vocal fold medialization relative to controls (28 to 55% vs. - 29 to 39% respectively, in the glottal area reduction), suggesting that this tool has the potential to improve outcomes and revision rates for type I thyroplasty.

Split cricoideo anterior posterior: una novedosa técnica para evitar la traqueotomía en parálisis cordal bilateral en pacientes pediátricos / Posterior anterior cricoid split: a cutting-edge technique to avoid tracheostomy in bilateral cordal paralysis in pediatric patients

Introducción: La parálisis cordal bilateral en aducción es la segunda causa de estridor congénito y genera una grave obstrucción de la vía aérea, debutando con estridor. La traqueotomía ha sido durante mucho tiempo el gold estándar para el tratamiento de esta afección, no exenta de complicaciones. Existen procedimientos que intentan evitar la traqueotomía, como el split cricoideo anterior posterior endoscópico (SCAPE). Objetivo: Presentar experiencia con SCAPE en pacientes pediátricos como tratamiento alternativo de parálisis cordal bilateral en aducción. Material y Método: Análisis retrospectivo de los resultados quirúrgicos obtenidos en pacientes con parálisis cordal bilateral en aducción tratados con SCAPE entre enero de 2016 y diciembre de 2019 en el Hospital Guillermo Grant Benavente de Concepción, Chile. Resultados: Siete pacientes se sometieron a SCAPE. Todos los pacientes presentaban insuficiencia respiratoria severa, cinco requirieron asistencia ventilatoria mecánica. Seis pacientes tenían el diagnóstico de parálisis cordal bilateral (PCB) congénita y uno PCB secundaria a tumor de tronco cerebral. Cuatro pacientes presentaron comorbilidad de la vía aérea: dos pacientes presentaron estenosis subglótica grado I y dos pacientes presentaron laringomalacia que requirió manejo quirúrgico. Los días promedio de intubación fueron once días. Ningún paciente requirió soporte ventilatorio postoperatorio, sólo un paciente recibió oxigenoterapia nocturna debido a hipoventilación secundaria a lesión de tronco. Ningún paciente ha presentado descompensación respiratoria grave. Un 40% ha recuperado movilidad cordal bilateral. Conclusión: Split cricoideo anteroposterior endoscópico es una alternativa eficaz para tratar el PCB en pacientes pediátricos. Nuestro estudio evidencia que es una alternativa a la traqueotomía, con excelentes resultados y menor morbimortalidad.

Introduction: Bilateral vocal fold paralysis in adduction is the second cause of congenital stridor and generates a serious obstruction of the airway. Tracheostomy has long been the gold standard for the treatment of this condition, but it has inherent complications. There are procedures that try to avoid tracheotomy, such as the endoscopic anterior posterior cricoid split (EAPCS). Aim: Present our experience with EAPCS in pediatric patients as a treatment for bilateral vocal fold paralysis in adduction. Material and Method: Retrospective analysis of the surgical results obtained in patients with bilateral vocal cord paralysis in adduction treated with EAPCS between January 2016 and December 2019 at Guillermo Grant Benavente Hospital in Concepción, Chile. Results: Seven patients underwent EAPCS. All patients had severe respiratory failure, five required mechanical ventilation assistance. Six patients were diagnosed with congenital bilateral cord palsy (BCP) and one BCP secondary to a brainstem tumor. Four patients had airway comorbidity: two patients had grade I subglottic stenosis and two patients had laryngomalacia that required surgical management. The average days of intubation were eleven days. No patient required post op invasive/non-invasive ventilation, only one patient received nocturnal oxygen therapy due to hypoventilation secondary to trunk injury. None of the patients has presented severe respiratory decompensation. Forty percent have recovered bilateral chordal mobility. Conclusion: SCAPE is a cutting-edge and effective alternative to treat PCB in pediatric patients. Our study shows that it is an alternative to tracheotomy, with excellent results and lower morbidity and mortality.

Improving Timeliness of Vocal Fold Mechanical Injury Screening Following Norwood or Arch Reconstruction: A Quality Improvement Initiative at a Single Center.

Vocal fold (VF) immobility is a common complication after pediatric cardiothoracic surgeries involving the aortic arch and conotruncal region. Nasolaryngoscopy is considered the standard for diagnosis but is invasive and requires expertise and special resources. VF ultrasound (VF US) is an efficient, non-invasive alternative for VF evaluation in the post-cardiac surgical setting. Our aim was to improve screening rates for vocal fold motion impairment (VFMI) by implementing VF US in a group of pre-identified high-risk patients after index cardiac surgeries using Quality Improvement (QI) methodology. The QI project included formation of a widely representative stakeholder team, collaborative development of a screening protocol for the cohort of patients in our tertiary center. Baseline data were derived by retrospective review of screening and incidence of VFMI in a similar post-surgical cohort in 2 years prior to this intervention. We implemented an US screening algorithm with multidisciplinary care coordination. We evaluated feeding practices and length of stay (LOS) related to our screening interventions and documented follow up practices. Screening for VFMI by ultrasound increased from 59 to 92% after implementation of the VF screening protocol. Additionally, time between extubation and VF US decreased from 7.7 to 2.3 days. The positive predictive value of VF US was 96%. Patients with VFMI had a longer LOS and greater dependence on tube feeds at discharge after index surgery. We successfully implemented an ultrasound-based screening protocol for VFMI and demonstrated improved screening, timeliness and high positive predictive value of ultrasound.

Transient Recurrent Laryngeal Nerve Palsy after Interventional Therapy.

BACKGROUND: Hoarseness due to laryngeal nerve injury is a known complication after cardiothoracic surgery involving the aortic arch. However, this complication is only rarely reported after catheter interventions. RESULTS: In this article we present the unusual case of a left-sided vocal cord paralysis in four patients after primary stenting of a re-coarctation, re-dilatation of a stented coarctation, a primary stenting of the left pulmonary artery (LPA), and prestenting for percutaneous pulmonary valve implantation with dilation of the LPA. After implanting bare metal stents, it is common practice, whilst contemplating the diameters of the adjacent structures, to optimize the stent diameter in a two-step procedure and dilate the stent until a maximum diameter is achieved and there is no residual gradient after applying this technique. Four of our patients experienced hoarseness after the intervention and a vocal cord paralysis was diagnosed. Angiography revealed no signs of extravasation or dissection. Clinical symptoms improved over the course of the following 6 months; patients with interventions at the aortic arch showed a complete remission, patients with procedures involving the LPA showed only mild regression of the symptoms. CONCLUSION: To our knowledge, this complication (Ortner's syndrome, cardiovocal syndrome) after such interventions has rarely been reported before. Although a rare complication, the recognition of these symptoms may support colleagues in managing affected patients. In addition, awareness for hoarseness after interventional therapies and systematic screening for this complication might help to identify patients at risk in the future.

Assessment of survey radiography as a method of diagnosing bilateral laryngeal paralysis in dogs.

The gold standard for diagnosis of laryngeal paralysis is laryngoscopy under light anesthesia. This prospective analytical cross-sectional study aimed to determine whether a radiographic assessment of the larynx could be used as a non-invasive screening tool for diagnosing laryngeal paralysis in non-sedated animals, as the laryngeal ventricles may appear wider in affected animals. The laryngeal ventricles of 18 dogs with bilateral laryngeal paralysis composing the affected group and 25 non-sedated dogs presenting no respiratory abnormality composing the control group were evaluated using right lateral radiography of the larynx. Three observers measured the ratios of the maximal ventricular length and surface to the body length of the third cervical vertebra (MVL/LC3 and VS/LC3, respectively). They also subjectively assessed the ventricular shape as either normal or rounded. The most accurate criterion was found to be MVL/LC3, as the respective areas under the ROC curves were 0.96 (95% confidence interval [CI]: 0.95-0.97), 0.89 (95% CI: 0.87-0.91), 0.80 (95% CI: 0.65-0.95) for MVL/LC3, VS/LC3, and ventricular shape evaluation, respectively. Based on ROC curve analysis, two thresholds of clinical interest were set for the MVL/LC3; bilateral laryngeal paralysis was very unlikely for values < 0.3 and very likely for values > 0.5. The findings of this study support the use of lateral laryngeal radiography as a screening tool for diagnosing bilateral laryngeal paralysis. However, further diagnostic tests remain required if MVL/LC3 lies between these threshold values or if clinically indicated. Further studies are warranted to explore the use of laryngeal radiography in unilateral paralysis and other laryngeal or oropharyngeal diseases.

Intraoperative computed tomography imaging for laryngoplasty.

OBJECTIVES: Intraoperative cone beam computed tomography (CBCT) imaging has the potential to facilitate the surgical procedure. The current preliminary retrospective chart review investigated the benefits of intraoperative CBCT during laryngoplasty. METHOD: This study examined 26 cases that underwent intraoperative CBCT imaging during laryngoplasty, with one patient who counted twice due to first and revision surgery. The visual quality of structures of interest (glottal shape, thyroid cartilage, arytenoid cartilage, and implants) was determined using intraoperative CBCT during laryngoplasty. Each patient also underwent an aerodynamic assessment. RESULTS: CBCT provided unique information, such as surgical landmarks in severe scarring, the subglottal shape, and the rotation angle of the arytenoid cartilage during arytenoid adduction. Nonetheless, 26.9% (7 of 26) of cases were affected by motion artifact, due to the long acquisition time. When motion artifact-negative cases were evaluated, 100% of glottal shape and more than 89% of thyroid cartilage were well visualized. All arytenoids were well-visualized in patients ≥ 50 years of age and without motion artifact, while CBCT failed to visualize the arytenoids in 2 of 4 patients who were < 50 years, due to the lack of calcifications. After medialization surgery, the yields of improved maximal phonation times (MPTs) in the motion artifact-negative and -positive groups were 8.7 sec and 3.4 sec, respectively (p = 0.032; Welch's t test). This comparison indicates intraoperative CBCT would contribute in MPT improvement, if CBCT is taken in measurable quality. CONCLUSION: The potential benefits of intraoperative CBCT during laryngoplasty were demonstrated. A corollary, prospective study is warranted to further confirmation.

When The Silence Prevails, Images Talk: The Characteristic Ct Features Of Vocal Cord Paralysis, Causes Of Missed Palsy By Radiologists And Mimics Of Vocal Cord Palsy Unveiled.

BACKGROUND: Causes of vocal cord palsy (VCP) can be identified even before its clinical presentation if a radiologist has knowledge about signs of vocal cord palsy, its various mimics and the anatomy of recurrent laryngeal nerve. Objectives are to know the signs and underlying causes leading to VCP and various mimics which may lead to the false positive diagnosis of VCP. METHODS: A retrospective cross-sectional pilot study comprising 54 patients with vocal cord palsy proven by IDL was conducted. 3 groups were identified. The first group comprised missed VCP on cross-sectional imaging. The second group was, of missed cause of VCP in patients with clinical diagnoses. The third group was patients with mimics of the palsy. RESULTS: Thirteen (76.5%) patients had missed diagnosis due to lack of knowledge of signs and 23.5% due to lack of time, overwork and tiredness. A vigilant search for the cause was not done in 31.6% of patients and in 68.4% of patients, the cause was identified but not correlated. A total of 8 patients had false positive diagnoses due to failure to differentiate from mimics. CONCLUSIONS: There is an increasing trend of missed diagnosis of vocal cord palsy on cross-sectional imaging in patients with established clinical diagnosis due to a lack of knowledge of VCP signs and missed causes along the course of recurrent laryngeal nerve.

Integrated basic lung and heart ultrasound with X-ray (TUSX) for the diagnosis of asthma, chronic bronchitis and laryngeal paralysis, and treatment with inhaled fluticasone using home-made mask in dogs and cats.

Basic lung and heart ultrasound examination combined with chest X-ray (TUSX) is currently considered to be very useful for differentiation of asthma, chronic bronchitis and laryngeal paralysis from other diseases with dyspnea/coughing. Among 252 client-owned animals with persistent dyspnea/cough/noisy breathing, in 197 of them: pulmonary edema, pneumonia, lung cancer, free pleural fluid, pneumothorax, lung contusion or heart disease were diagnosed. The remaining 55 animals (42 dogs and 13 cats) were diagnosed with asthma (in 13 cats), chronic bronchitis (in 37 dogs) and laryngeal paralysis (in 5 dogs) using TUSX. These animals were qualified for inhaled fluticasone treatment using 3 types of spacers - two commercial and a home- -made mask. 36 animals (65.5%) completed the trail. In 26 of them (72.2%) the owners observed complete, long lasting relief of the symptoms, and the owners of 7 animals (19.5%) declared a considerable clinical improvement, regardless of the type of spacer used. The owners of 3 animals (8.3%) did not see any improvement. The proposed diagnostic and therapeutic management improved long-term clinical status of the vast majority (91.7%) of animals. Therefore, it seems justified to include the TUSX diagnostic protocol in daily veterinary practice and to encourage owners to prepare home-made face masks for inhaled fluticasone treatment.

Giant aortic arch aneurysm presenting with hoarseness of voice.

A middle-aged male with hypertension and dyslipidaemia presented with hoarseness of voice due to a left vocal palsy. The chest radiograph revealed a saccular opacity silhouetting the left border of the aortic knuckle, suggestive of a large aortic arch aneurysm. Routine investigations, such as a chest radiograph do occasionally identify potentially fatal pathology, even when perhaps not strictly indicated; uncommon presentations do occur!

Feasibility and accuracy of laryngeal ultrasound for the assessment of vocal cord mobility in children.

OBJECTIVE: Transcutaneous laryngeal ultrasonography has been utilized to document vocal cord mobility in the adult perioperative thyroidectomy setting with variable success. The aims of this study were to assess the feasibility of using transcutaneous ultrasound in vocal cord visualization in children, to determine the accuracy in detecting vocal cord immobility compare to flexible laryngoscopy, and to identify any barriers that may affect its utility. METHODS: This is a prospective blinded-assessor study. Transcutaneous laryngeal ultrasound and flexible laryngoscopy were performed in two pediatric settings: perioperative thyroid surgery and inpatient consultation for airway, voice, or swallowing concerns. The video recordings of ultrasound and laryngoscopy were assessed by two fellowship-trained pediatric otolaryngologists independently. RESULTS: A total of 83 paired laryngoscopy and ultrasound assessments were performed, 39 for perioperative thyroidectomy and 44 for inpatient consultation. The majority had normal vocal cord mobility (65/83, 78%), while 16 had unilateral cord palsy and 2 had bilateral palsy. The vocal cords were successfully visualized on ultrasound in 82/83 (99%) evaluations. Compared to gold standard laryngoscopy, the sensitivity for diagnosing vocal cord palsy on ultrasound was 53-83%, and the specificity was 97-98%. The sensitivity for detecting asymmetric vocal cord movement was 56-88%, and the specificity was 99%. The agreement between ultrasound and laryngoscopy diagnoses were 87-94% (κ = 0.58-0.83, moderate to near perfect agreement). The intra-rater agreement was 95-100% (κ = 0.64-1.0), and inter-rater agreement was 90% (κ = 0.66). Both subjects with bilateral vocal cord palsy had incorrect ultrasound diagnoses by both observers. CONCLUSION: We were able to utilize transcutaneous laryngeal ultrasound to successfully visualize vocal cord mobility in almost all pediatric patients with a high degree of specificity. The modality has limitations in the assessment of bilateral vocal cord palsy, and its sensitivity was observer-dependent.