Advertisement

The Poor Validity of Asymmetric Laryngoscopic Findings in Predicting Laterality in Vocal Fold Paresis

Published:October 17, 2020DOI:https://doi.org/10.1016/j.jvoice.2020.09.004

      Summary

      Objective

      To determine the laryngoscopic findings most predictive of laterality in vocal fold paresis in patients with known RLN and/or SLN paresis by laryngeal electromyography (LEMG).

      Study design

      Blinded, prospective video perceptual analysis study.

      Methods

      Patients with vocal fold paresis diagnosed by LEMG at a tertiary care hospital from 2017 to 2019 were identified. Two fellowship-trained laryngologists blinded to clinical history and LEMG results reviewed laryngostroboscopic examinations and assessed for evidence of paresis using defined criteria. Inclusion criteria were adults with laryngeal asymmetry and evidence of decreased recruitment on LEMG. Exclusion criteria were children, presence of laryngeal lesions, myasthenia gravis, vocal fold paralysis, and normal laryngeal symmetry.

      Results

      We identified 95 patients who were diagnosed with vocal fold paresis with LEMG who met inclusion and exclusion criteria (mean age 43.8 ± 20.4 years (18-88), 38.9% male). When comparing the laterality of the observed laryngoscopic finding with LEMG, we found that in patients who had severe true vocal fold (TVF) range of motion disturbance, the laterality of the finding matched the LEMG distribution of paresis in 12 out of 13 (92.3%) patients (P = 0.002). No other laryngoscopic findings reliably predicted laterality including corniculate and cuneiform cartilage asymmetry, pyriform sinus dilation, abnormal TVF show, petiole deviation, abnormal ventricular show, increased supraglottic area, and FVF hyperfunction of the opposite side.

      Conclusion

      With the exception of severe TVF range of motion disturbance, there seems to be poor validity of laryngoscopic findings in predicting the affected side in vocal fold paresis. We recommend neurophysiologic testing to confirm the clinical diagnosis of vocal fold paresis.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Voice
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Imamura R
        • Marcelo AM
        • Tsuji DH
        Isolated paresis of laryngeal adduction: what are the laryngoscopic and stroboscopic findings?.
        Laryngoscope. 2019; 129: 919-925
        • Harris G
        • O'Meara C
        • Pemberton C
        • et al.
        Vocal fold paresis - a debilitating and underdiagnosed condition.
        J Laryngol Otol. 2017; 131: S48-S52
        • Estes C
        • Sadoughi B
        • Mauer E
        • et al.
        Laryngoscopic and stroboscopic signs in the diagnosis of vocal fold paresis.
        Laryngoscope. 2017; 127: 2100-2105
        • Sataloff RT
        • Praneetvatakul P
        • Heuer RJ
        • et al.
        Laryngeal electromyography: clinical application.
        J Voice. 2010; 24: 228-234
        • Heman-Ackah YD
        • Barr A
        Mild vocal fold paresis: understanding clinical presentation and electromyographic findings.
        J Voice. 2006; 20: 269-281
        • Bielamowicz S
        • Kapoor R
        • Schwartz J
        • et al.
        Relationship among glottal area, static supraglottic compression, and laryngeal function studies in unilateral vocal fold paresis and paralysis.
        J Voice. 2004; 18: 138-145
        • Persky M
        • Sanders B
        • Rosen CA
        • et al.
        False vocal fold characteristics in presbylarynges and recurrent laryngeal neuropathy.
        Ann Otol Rhinol Laryngol. 2017; 126: 42-46
        • Roy N
        • Barton ME
        • Smith ME
        • et al.
        An in vivo model of external superior laryngeal nerve paralysis: laryngoscopic findings.
        Laryngoscope. 2009; 119: 1017-1032
        • Sufyan AS
        • Kincaid JC
        • Wannemuehler TJ
        • et al.
        The interarytenoid spatial relationship: accuracy and interrater reliability for determining sidedness in cases of unilateral adductor paresis.
        J Voice. 2013; 27: 90-94
        • Wu AP
        • Sulica L.
        Diagnosis of vocal fold paresis: current opinion and practice.
        Laryngoscope. 2015; 125: 904-908
        • Simpson CB
        • Cheung EJ
        • Jackson CJ
        Vocal fold paresis: Clinical and electrophysiologic features in a tertiary laryngology practice.
        J Voice. 2009; 23: 396-398
        • Koufman JA
        • Postma GN
        • Cummins MM
        • et al.
        Vocal fold paresis.
        Otolaryngol Head Neck Surg. 2000; 122: 537-541
        • Stager SV
        Vocal fold paresis: etiology, clinical diagnosis and clinical management.
        Curr Opin Otolaryngol Head Neck Surg. 2014; 22: 444-449
        • Koufman JA
        • Postma GN
        • Whang CS
        • et al.
        Diagnostic laryngeal electromyography: the wake forest experience 1995-1999.
        Otolaryngol Head Neck Surg. 2001; 124: 603-606
        • Sataloff RT
        • Mandel S
        • Mann EA
        • et al.
        Practice parameter: laryngeal electromyography (an evidence-based review).
        Otolaryngol Head Neck Surg. 2004; 130: 770-779
        • Sittel C
        • Stennert E
        • Thumfart WF
        • et al.
        Prognostic value of laryngeal electromyography in vocal fold paralysis.
        Arch Otolaryngol Head Neck Surg. 2001; 127: 155-160
        • Isseroff TF
        • Parasher AK
        • Richards A
        • et al.
        Interrater reliability in analysis of laryngoscopic features for unilateral vocal fold paresis.
        J Voice. 2016; 30: 736-740
        • Barbosa J
        • Lee K
        • Lee S
        • et al.
        Efficient quantitative assessment of facial paralysis using iris segmentation and active contour-based key points detection with hybrid classifier.
        BMC Med Imaging. 2016; 16 (23-016)
        • Barbosa J
        • Seo WK
        • Kang J
        paraFaceTest: an ensemble of regression tree-based facial features extraction for efficient facial paralysis classification.
        BMC Med Imaging. 2019; 19 (30-019)
        • Simpson CB
        • May LS
        • Green JK
        • et al.
        Vibratory asymmetry in mobile vocal folds: is it predictive of vocal fold paresis?.
        Ann Otol Rhinol Laryngol. 2011; 120: 239-242
        • Woo P
        • Parasher AK
        • Isseroff T
        • et al.
        Analysis of laryngoscopic features in patients with unilateral vocal fold paresis.
        Laryngoscope. 2016; 126: 1831-1836
        • Dilworth TF.
        The nerves of the human larynx.
        J Anat. 1921; 56: 48-52
        • Henry BM
        • Pekala PA
        • Sanna B
        • et al.
        The anastomoses of the recurrent laryngeal nerve in the larynx: a meta-analysis and systematic review.
        J Voice. 2017; 31: 495-503
        • Maranillo E
        • Leon X
        • Quer M
        • et al.
        Is the external laryngeal nerve an exclusively motor nerve? The cricothyroid connection branch.
        Laryngoscope. 2003; 113: 525-529
        • Sanudo JR
        • Maranillo E
        • Leon X
        • et al.
        An anatomical study of anastomoses between the laryngeal nerves.
        Laryngoscope. 1999; 109: 983-987
        • Maranillo E
        • Leon X
        • Orus C
        • et al.
        Variability in nerve patterns of the adductor muscle group supplied by the recurrent laryngeal nerve.
        Laryngoscope. 2005; 115: 358-362