Research Article|Articles in Press

Visual Interpretation of Vocal Fold Paralysis in Flexible Laryngoscopy Using Eye Tracking Technology



      Interpretation of laryngoscopy is an important diagnostic skill in otolaryngology. There is, however, limited understanding of the specific visual strategies used while assessing flexible laryngoscopy video. Eye-tracking technology allows for objective study of eye movements during dynamic tasks. The purpose of the present study was to explore visual gaze strategies during laryngoscopy interpretation of unilateral vocal fold paralysis (UVFP) across clinician experience from novice to expert.


      Thirty individuals were shown five flexible laryngoscopy videos, each 10 seconds long. After viewing each video, participants reported their impressions of “left vocal fold paralysis,” “right vocal fold paralysis,” or “no vocal fold paralysis.” Eye tracking data were collected and analyzed for duration of fixation and number of fixations on select areas of interest (AOI). Diagnostic accuracy and visual gaze patterns were compared between novice, experienced, and expert groups.


      Diagnostic accuracy among learners in the novice group was significantly lower than those in the more experienced groups (P = 0.04). All groups demonstrated similar visual gaze patterns when viewing the video with normal bilateral vocal fold mobility, spending the greatest percentage of time viewing the trachea. There were differences among groups when viewing the videos of left or right VFP, but the trachea was always in the top three structures for greatest fixation duration and highest number of fixations.


      Eye-tracking is a novel tool in the setting of laryngoscopy interpretation. With further study it has the potential to be useful for the training of otolaryngology learners to improve diagnostic skills.

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


        • Grundfast KM
        • Harley E
        Vocal cord paralysis.
        Otolaryngol Clin North Am. 1989; 22: 569-597
        • Rosow DE
        • Sulica L
        Laryngoscopy of vocal fold paralysis: evaluation of consistency of clinical findings.
        Laryngoscope. 2010; 120: 1376-1382
        • Almansa C
        • Shahid MW
        • Heckman MG
        • et al.
        Association between visual gaze patterns and adenoma detection rate during colonoscopy: a preliminary investigation.
        Am J Gastroenterol. 2011; 106: 1070-1074
        • Tourassi G
        • Voisin S
        • Paquit V
        • et al.
        Investigating the link between radiologists' gaze, diagnostic decision, and image content.
        J Am Med Inform Assoc. 2013; 20: 1067-1075
        • Chetwood ASA
        • Kwok K
        • Sun L
        • et al.
        Collaborative eye tracking: a potential training tool in laparoscopic surgery.
        Surg Endosc. 2012; 26: 2003-2009
        • Ashraf H
        • Sodergren MH
        • Merali N
        • et al.
        Eye-tracking technology in medical education: a systematic review.
        Med Teacher. 2017; 40: 62-69
        • Chetwood AS
        • Kwok KW
        • Sun LW
        • et al.
        Collaborative eye tracking: a potential training tool in laparoscopic surgery.
        Surg Endosc. 2012; 26: 2003-2009
        • Brook CD
        • Platt MP
        • Russell K
        • et al.
        Time to competency, reliability of flexible transnasal laryngoscopy by training level: a pilot study.
        Otolaryngol Head Neck Surg. 2015; 152: 843-850
        • Tasli H
        • Karakoc O
        • Birkent H
        A grading system for transnasal flexible laryngoscopy.
        J Voice. 2019; 33: 712-715
        • Russell KA
        • Brook CD
        • Platt MP
        • et al.
        The benefits and limitations of targeted training in flexible transnasal laryngoscopy diagnosis.
        JAMA Otolaryngol Head Neck Surg. 2017; 143: 707-711
        • Maurrasse SE
        • Li C
        • Modi VK
        Pediatric flexible laryngoscopy: trends in diagnostic abilities throughout training.
        Int J Pediatr Otorhinolaryngol. 2020; 129109740
        • Liu YF
        • Kim CH
        • Bailey TW
        • et al.
        A prospective assessment of nasopharyngolaryngoscope recording adaptor use in residency training.
        Otolaryngol Head Neck Surg. 2016; 155: 710-713
        • Lozada KN
        • Morton K
        • Stepan K
        • et al.
        The clinical impact of bedside fiberoptic laryngoscopic recording on a tertiary consult service.
        Laryngoscope. 2018; 128: 818-822
        • Stewart EEM
        • Valsecchi M
        • Schütz AC
        A review of interactions between peripheral and foveal vision.
        J Vis. 2020; 20: 2
        • Wood BP
        Visual expertise.
        Radiology. 1999; 211: 1-3
        • Myles-Worsley M
        • Johnston W
        • Simons M
        The influence of expertise on X-ray image processing.
        J Exp Psychol Learn Mem Cogn. 1988; 14: 553-557
        • Green DE
        • Maximin S
        Professional coaching in radiology: practice corner.
        Radiographics. 2015; 35: 971-972
        • Duvivier RJ
        • van Dalen J
        • Muijtjens AM
        • et al.
        The role of deliberate practice in the acquisition of clinical skills.
        BMC Med Educ. 2011; 11: 101