Use of Audiometric Measurement for Assessment of Vocal-Fold Function in Postextubation Infants

Validated mobile applications in otolaryngology head and neck surgery for patient and physicians: A systematic literature review

IMPORTANCE

Mobile apps in the field of ORL-HNS, are widely used by patients and physicians, but neither necessarily developed in collaboration with healthcare professionals nor subjected to regulations by the United States Food and Drug Administration guidelines, with a resultant potential of risk for its users.

OBJECTIVE

To provide the ORL-HNS physician with an updated list of scientific peer review literature- validated mobile apps for safe use for both the clinician and the patients, for screening, diagnosis, therapy and follow up for various ORL-HNS pathologies.

EVIDENCE REVIEW

A comprehensive systematic review of the scientific literature was conducted in "PubMed," "EMBASE," and "Web of Science" without limitation of publication date up to January 1st, 2023. The included papers validated mobile apps in the ORL-HNS discipline. Each study was evaluated using the "Strengthening the Reporting of Observational Studies in Epidemiology" (STROBE) tool.

FINDINGS

From the thousands of unregulated ORL-HNS mobile apps available for download and use in the various app stores, only 17 apps were validated for safe use by the clinician and/or patient. Their information is listed.

CONCLUSIONS AND RELEVANCE

The limited number of validated mobile apps highlights the importance to use validated apps in clinical practice, to improve evidence-based medicine and patient safety. Physician are encouraged to use and recommend their patients to use validated mobile apps only, like any other tool in clinical practice in the evidence-based era.

Recorded Flexible Nasolaryngoscopy for Neonatal Vocal Cord Assessment in a Prospective Cohort

OBJECTIVE

Assessing vocal cord mobility by flexible nasolaryngoscopy (FNL) can be difficult in neonates. To date, prospective studies evaluating the incidence and diagnostic accuracy of vocal cord paralysis (VCP) after surgical patent ductus arteriosus (PDA) ligation are limited. It is unknown whether video FNL improves diagnosis in this population. This study compared video recordings with bedside evaluation for diagnosis of VCP and determined inter-rater reliability of the diagnosis of VCP in preterm infants after PDA ligation.

METHODS

Prospective cohort of preterm neonates undergoing bedside FNL within two weeks of extubation following PDA ligation. In a subset, FNL was recorded. Two pediatric otolaryngologists, blinded to the initial diagnosis, reviewed the FNL video recordings.

RESULTS

Eighty infants were enrolled and 37 with a recorded FNL were included in the cohort. Average gestational age at birth was 25.2 weeks (SD: 1.2) and postmenstrual age at FNL was 37.0 weeks (SD: 4.5), which was 9.5 days (SD: 14.7) after extubation following PDA repair. There were 6 diagnosed with left VCP (16.2%; 95% CI: 4.3-28.1%) at bedside, and 9 diagnosed by video review (24.3%; 95% CI: 10.5-38.1%) (P = .56). Videos confirmed all 6 VCP diagnosed initially, but also identified 3 additional cases. Though imperfect, reviewing FNL by video showed substantial reliability (kappa = .75), with 91.9% agreement.

CONCLUSION

Video recorded FNL most often confirms a bedside diagnosis of VCP, but may also identify discrepancies. Physicians should consider the limitations of diagnosis especially when infants persist with symptoms such as weak voice or signs of postoperative aspiration.

LEVEL OF EVIDENCE

2b.

Neonatal Vocal Fold Paralysis

Vocal fold paralysis (VFP) is an important cause of respiratory and feeding compromise in infants. The causes of neonatal VFP are varied and include central nervous system disorders, birth-related trauma, mediastinal masses, iatrogenic injuries, and idiopathic cases. Bilateral VFP often presents with stridor or respiratory distress and can require rapid intervention to stabilize an adequate airway. Unilateral VFP presents more subtly with a weak cry, swallowing dysfunction, and less frequently respiratory distress. The etiology and type of VFP is important for management. Evaluation involves direct visualization of the vocal folds, with additional imaging and testing in select cases. Swallowing dysfunction, also known as dysphagia, is very common in infants with VFP. A clinical assessment of swallowing function is necessary in all cases of VFP, with some patients also requiring an instrumental swallow assessment. Modification of feeding techniques and enteral access for feedings may be necessary. Airway management can vary from close monitoring to noninvasive ventilation, tracheostomy, and laryngeal surgery. Long-term follow-up with otolaryngology and speech-language pathology service is necessary for all children with VFP to ensure adequate breathing, swallowing, and phonation. The short- and long-term health and quality-of-life consequences of VFP can be substantial, especially if not managed early.

The reliability of flexible nasolaryngoscopy in the identification of vocal fold movement impairment in young infants

OBJECTIVE

Flexible nasolaryngoscopy (FNL) is considered the gold standard for evaluation of vocal fold mobility but there has been no data on the reliability of interpretation in the infant population. Visualization may be limited by excessive movement, secretions, or floppy supraglottic structures that prevent accurate diagnosis of vocal fold movement impairment (VFMI). We sought to evaluate the inter- and intra-rater reliability of FNL for the evaluation of VFMI in young infants.

STUDY TYPE

Case-control.

METHODS

Twenty infants were identified: 10 with VFMI and 10 normal as seen on FNL. Three pediatric otolaryngologists reviewed the video without sound and rated the presence and/or degree of vocal fold mobility. Twelve videos were repeated to assess intra-rater reliability.

RESULTS

There was substantial agreement between the reviewers regarding the identification normal vs. any type of VFMI (kappa = 0.67) but only moderate agreement regarding the degree of vocal fold movement (kappa = 0.49). Intra-rater reliability ranges from moderate to perfect agreement (kappa = 0.48-1).

CONCLUSION

FNL in infants is an extremely challenging procedure. Clinically, physicians frequently use the quality of the cry and the past medical and surgical history to help make a judgment of vocal fold movement when the view is suboptimal. These other factors, however, may bias the interpretation of the FNL. Without sound, there is only moderate inter-rater and variable intra-rater reliability for the identification of degree of movement on FNL. Otolaryngologists must be cognizant of the limitations of FNL when using it as a clinical tool or as a "gold standard" against which other modalities are measured.