Laboratory Evaluation of Vocal Fold Paralysis and Paresis

Gender Differences in Vocal Fold Mass Treatment

OBJECTIVE

The purpose of the study was to examine gender-related differences in benign vocal fold mass treatment.

METHODS

Adult patient with vocal fold mass diagnosed on strobovideolaryngoscopy examination were reviewed retrospectively. Patient demographics, past medical history, laboratory data, and examination findings during the initial visit and at follow-up were collected. The duration of voice therapy and the prevalence of surgery were analyzed for males and females.

RESULTS

One hundred and fifty-eight patients (76 male and 82 female) were included. The percentage of professional voice users differed significantly between males and females. Vocal folds of females had a higher percent of reactive masses present. Females were also more likely to have a pseudocyst. Vocal folds of males showed a higher percent of masses of unspecified category on strobovideolaryngoscopy examination. A significantly greater proportion of females had abnormal high shimmer values, and abnormal low maximum phonation time; and a significantly greater proportion of females compared to males chose to participate in voice therapy. The average number of voice therapy sessions for males did not differ, nor did duration of voice therapy. A similar proportion of males and females underwent surgical mass excision. The treatment plan completed differed significantly between males and females with a higher percentage of males choosing to receive no treatment. For 45.54% of males and 59.70% of females the treatment plan consisted of voice therapy only. For 33.33% of males and 37.31% of females, the treatment plan included both voice therapy and surgery. Although gender was the strongest predictor for participation in voice therapy, professional voice uses also predicted participation in voice therapy in both men and women significantly. Professional singing in particular was not a significant predictor for participation in voice therapy. Males were significantly more likely than females to be lost to follow-up before treatment outcome could be assessed CONCLUSION: More females than males were found to have pseudocysts while more males than females had unspecified masses. Females and professional voice users were more willing than males to utilize voice therapy. No difference was found between males and females who decided to have surgery. The best treatment regimen for vocal fold mass is a combination of voice therapy and surgery, when necessary, but gender-specific differences merit further research as well as reconsideration of therapy approaches and strategies to optimize patient compliance.

Vocal Fold Paresis and Voice Outcomes following Vocal Fold Mass Excision

OBJECTIVE

To correlate the surgical results of vocal fold mass excision with pre-operative existence of vocal fold paresis.

METHODS

Data were collected on 66 patients who underwent excision of benign vocal fold masses from 2015 to 2020. The pre- and post-operative strobovideolaryngoscopy (SVL) examinations for all patients included were evaluated blindly by three otolaryngologists using THE Voice-Vibratory Assessment with Laryngeal Imaging (VALI) Form for scar severity, mucosal wave, free edge contour, glottal closure, and phase closure. The success of mass excision surgery was determined based on the presence of the following criteria post-operatively: 1) improved mucosal wave motion 2) improved phase closure or glottic closure 3) improved free edge contour and 4) lack of worsening of vocal fold scar severity. Surgery was considered successful if 3 or 4 criteria were met, partially successful if 1 or 2 criteria were met, and unsuccessful if no criteria were met. The percent recruitment of the thyroarytenoid, posterior cricoarytenoid (PCA), and cricothyroid muscles were used evaluated the severity of paresis as mild (70-99% recruitment), moderate (40-60% recruitment), or severe (0-39% recruitment). VHI-10 scores were used as subjective measures of pre- and post-operative voice.

RESULTS

Sixty-six patients (26 male, 40 female) were included in this study, with a mean age of 37.25 ± 16.6 (range 18-78). Twelve patients had no evidence of VF paresis noted during the initial clinical evaluation; and 52 patients had paresis and had undergone laryngeal EMG. 81% of these patients had mild paresis, 12.8% had moderate paresis, and 5.8% had severe paresis. Based on pre- and post-operative strobovideolaryngoscopy, there was improvement in mucosal wave in 44.9% of cases, improvement of phase or glottic closure in 85.4% of cases, improved free edge contour in 95.5% of cases, and worsening of scar in 38.5% of cases. 39.6% of surgeries were fully successful, 33.3% of surgeries were partially successful, and 27.1% were not successful. There was a significant correlation between female gender and vocal fold paresis (P = 0.048). Paresis severity did not correlate with complete or partial surgical success (P = 0.956), pre-operative VHI-10 scores (P = 0.519), post-operative VHI-10 scores (P = 0.563), or strobovideolaryngoscopy parameters. Unilateral and bilateral paresis did not correlate with any other parameter of surgical success (P >0.05).

CONCLUSION

This study suggests that there is no correlation between pre-operative vocal fold paresis and voice outcomes after mass excision surgery, that the majority of mass excision surgeries (72.9%) are successful based on improvement in stroboscopic parameters, and that the proportion of patients with moderate and severe paresis is consistent across all laryngeal nerves.

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.

Endoscopic percutaneous suture lateralization with syringe needles for neonatal bilateral vocal cord paralysis

OBJECTIVE

To explore the novel technique of percutaneous endoscopic suture lateralization for bilateral vocal cord paralysis (BVCP) in neonates from Shenzhen, China, and to evaluate the safety and efficacy of the operation.

METHODS

In this retrospective case series, we present four neonates with BVCP diagnosed within 3 days after birth from Shenzhen Children's Hospital. All had stridor, respiratory distress and hypoxemia requiring respiratory support at diagnosis. Endoscopic vocal fold lateralization was performed under general anesthesia using 3.0 mm endotracheal intubation through the improved technique of percutaneous needle-directed placement of a 4-0 Prolene suture, without the use of specialized equipment. A 4-0 Prolene wire was led out through two 10 ml syringe needles, the left vocal cord was fully moved and fixed under the skin with endoscopy monitoring.

RESULTS

Overall, 3/4 of the patients showed clinical improvement in stridor and dyspnea 2-3 weeks after the operation and avoided a tracheostomy, two of them could breathe and feed normally when they were discharged from hospital, and one patient had a weak ability to suck but could breathe normally. The last patient had to undergo a tracheotomy due to the poor improvement in respiratory distress. None of the babies experienced any complications from this surgery, but case four presented with a series of complications and other problems in postoperative care related to the tracheostomy. At the last follow-up (mean 8 months), complete function of the bilateral vocal cords was acquired in case two (6 months) and partial function of the vocal cords was acquired in case one (13 months), with the other cases still experiencing paralysis.

CONCLUSION

Endoscopic percutaneous suture lateralization may be a reversible, effective and minimally invasive primary treatment for neonatal BVCP. Most of neonates with BVCP undergoing this procedure avoided a tracheotomy.

Laboratory Evaluation of Spasmodic Dysphonia

OBJECTIVES

To evaluate the utility of comprehensive laboratory evaluation in patients with spasmodic dysphonia (SD).

STUDY DESIGN

Retrospective chart review.

METHODS

A review of the medical records of 40 patients diagnosed with spasmodic dysphonia from 2009-2018 was preformed to evaluate abnormal test results that were significant when compared with abnormal results of the general population and for any other clinically relevant pathology.

RESULTS

Erythrocyte sedimentation rate, ceruloplasmin levels, and anti-AChR were found to be elevated at levels considered statistically significant (p <0.05). Furthermore, we found levels of cholesterol, thyroid-stimulating hormone (TSH), T3, fasting blood glucose, creatine kinase, immunoglobulin, antinuclear antibody (ANA), and alpha-fetoprotein (AFP) levels to be abnormal at a greater rate in our population, but these were not statistically significant. Workup revealed several underlying conditions including thyroid neoplasms, hypothyroidism, and laryngopharyngeal reflux. Additionally, brain MRI revealed age-related ischemic pathology in an elevated number of patients, but with no obvious clinical sequalae.

CONCLUSION

There is an association between serological values and spasmodic dysphonia that can aid in diagnosing pathology, as well as establishing a directed workup. Additionally, our study shows the utility of comprehensive evaluation in identifying undetected disease.

The clinical value of a thorough diagnostic evaluation for neurotologic complaints

PURPOSE

Determine the clinical efficacy of comprehensive neurotologic testing in patients presenting with complaints of hearing loss, tinnitus and/or dizziness.

METHODS

This is a retrospective analysis of 1170 consecutive charts of patients who presented between 1980 and 2013 with neurotologic complaints. Demographic data, chief complaint, diagnostic imaging, audiograms, and blood tests were evaluated.

RESULTS

Retrospective analysis of 1170 patient charts was performed. 762/1170 (65%) patients presented with subjective hearing loss, 575/1170 (49%) with dizziness, and 657/1170 (56%) with tinnitus. Audiometric testing revealed hearing loss in 1059/1169 (91%) patients. 536/1120 (48%) patients had abnormalities on Magnetic Resonance Imaging, and 343/1087 (32%) on Computed Tomography imaging. Endocrine and immunologic testing revealed 108/1135 (9.5%) patients were hyperglycemic; 125/1124 (11%) patients had elevated TSH; 149/1141 (13%) patients had a positive ANA; and 82/1133 (7.2%) patients were positive for RF. 198/1083 (18%) of patients were positive for HLA-B35, 246/1083 (23%) for HLA-Cw4, 454/1083 (42%) for HLA-Cw7, and 747/1060 (70%) of patients had absent HLA-DR4. 112/1085 (10%) of patients were positive for anti-68kD antibodies and 154/936 (17%) for protein 0. Many patients were diagnosed with previously unrecognized medical conditions.

CONCLUSION

Comprehensive neurotological workup results in diagnoses that would go unrecognized otherwise, allowing patients to receive prompt treatment for medically important conditions, some of which may be causally related to their neurotologic complaints. However, the value of each study for routine testing of patients with neurotologic complaints remains controversial; and the evidence presented herein should help practitioners determine what studies should be included in their patient assessments.

The Clinical Course of Idiopathic Bilateral Vocal Fold Motion Impairment in Adults: Case Series and Review of the Literature

AIM

Steps for assessment and successful management of bilateral vocal fold motion impairment (VFMI) are (1) recognition of its presence, (2) identifying the etiology and factors restricting vocal fold motion, (3) evaluation of airway patency, and (4) establishing a management plan. No large series documenting the course and outcome of adult idiopathic bilateral VFMI has been published within the past 15 years.

METHODS

Retrospective chart review of adult patients with idiopathic bilateral VFMI at a tertiary academic center. A diagnosis was established if history, physical examination with laryngoscopy, and initial imaging excluded a cause. Records were reviewed for demographics, clinical characteristics, surgical intervention details, and length of follow-up.

RESULTS

Nine adult patients with idiopathic bilateral VFMI were identified. There were five males and four females with a mean age of 59.6 years. The mean follow-up period was 54.4 months (range, 6-111 months). Upon presentation to our laryngology service, three patients were advised observation, three patients were advised to undergo urgent tracheostomy, and three patients were advised to undergo elective surgery for airway management. By the end of the follow-up period, only four patients (4/9, 44.4%) were tracheostomy dependent, one of them was lost to follow-up after tracheostomy tub downsizing for decannulation.

CONCLUSIONS

To our best knowledge, this is the largest series so far of adult patients with idiopathic bilateral VFMI. Conservative treatment can be considered as an alternative to surgery in select cases.