Fibreoptic laryngoscopy in the assessment of laryngeal disorders

Consensus statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS-ES) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Office-based procedures in laryngology

Objective

Development of transnasal fiberoptic laryngoscopy, integration of an operative channel (OC), the advent of high-definition television imaging, with improvements in laser technology, cleared the way for office-based laryngology. Three treatment categories can be identified: bioendoscopy-guided biopsy; laryngeal injection; laser-assisted surgery.

Methods

26 patients underwent OBPs at the Otolaryngology Clinic of IRCCS Policlinico San Martino, Genoa, Italy. Sixty-eight procedures were performed: 60 for recurrent respiratory papillomatosis (RRP), 5 for unilateral vocal fold paralysis (UVFP) and 3 for glottic leukoplakias. Neoblucaine 5% was administrated through the operative channel, for local anaesthesia. All procedures were carried out with the physician standing behind the patient. Narrow band imaging (NBI – Olympus Medical) or i-scan (Pentax Medical) were used to enhance the accuracy of the biopsy thanks to identification of atypical vascular patterns. Laryngeal injections were made using a 25G flexible needle. Opera Evo (Quanta system IEC/EN 60825-1:2007) is a hybrid fibre laser that is used for “blanching” and vaporisation of RRP lesions and to treat selected leukoplakias that were previously biopsied.

Conclusions

No major complications occurred during the procedures.

Consensus Statement by the American Association of Clinical Endocrinology (AACE) and the American Head and Neck Society Endocrine Surgery Section (AHNS) on Pediatric Benign and Malignant Thyroid Surgery

OBJECTIVES

To provide a clinical disease state review of recent relevant literature and to generate expert consensus statements regarding the breadth of pediatric thyroid cancer diagnosis and care, with an emphasis on thyroid surgery. To generate expert statements to educate pediatric practitioners on the state-of-the-art practices and the value of surgical experience in the management of this unusual and challenging disease in children.

METHODS

A literature search was conducted and statements were constructed and subjected to a modified Delphi process to measure the consensus of the expert author panel. The wording of statements, voting tabulation, and statistical analysis were overseen by a Delphi expert (J.J.S.).

RESULTS

Twenty-five consensus statements were created and subjected to a modified Delphi analysis to measure the strength of consensus of the expert author panel. All statements reached a level of consensus, and the majority of statements reached the highest level of consensus.

CONCLUSION

Pediatric thyroid cancer has many unique nuances, such as bulky cervical adenopathy on presentation, an increased incidence of diffuse sclerosing variant, and a longer potential lifespan to endure potential complications from treatment. Complications can be a burden to parents and patients alike. We suggest that optimal outcomes and decreased morbidity will come from the use of advanced imaging, diagnostic testing, and neural monitoring of patients treated at high-volume centers by high-volume surgeons.

Pediatric flexible laryngoscopy: Trends in diagnostic abilities throughout training

OBJECTIVES

Our objectives were to evaluate the ability of residents to diagnose pathology of the pediatric larynx on laryngoscopy, to trend this ability throughout training, to compare their skills to pediatric otolaryngologists, and to determine whether reviewing digitally captured videos in slow motion, as opposed to a live exam, enhanced diagnostic abilities. In addition, we identified pathologies and anatomical sub-sites that posed diagnostic challenges.

METHODS

Qualtrics was used to design and distribute an online test, which included 15 pediatric laryngoscopy videos. Participants selected a diagnosis for each video after (1) watching it once at full speed and (2) watching the video multiple times in slow motion. Anonymous responses were exported into excel for statistical analysis, including T-test, ANOVA, and descriptive statistics.

RESULTS

There were 21 total participants. Median scores for full speed versus slow motion video review were 47% and 60% respectively. When analyzed by training level, there was no significant difference in scores for full speed videos, but there was a significant difference across groups for slow motion review (p = 0.04). Post Graduate Year (PGY) 4 residents and pediatric otolaryngologists performed best with an average of 69% and 77% respectively. Base of tongue, subglottic, and laryngeal cleft lesions were the most difficult to diagnose. Motor, laryngeal, and vallecular pathologies were more accurately identified.

CONCLUSIONS

The ability to diagnose pathology on pediatric laryngoscopy tends to improve throughout residency training. Slow motion review enhances diagnostic skills. Laryngeal and vallecular pathologies are more easily diagnosed than base of tongue and subglottic lesions.

Safety of flexible endoscopic biopsy of the pharynx and larynx under topical anesthesia

Recent advancements in transnasal endoscopy enable a shift in diagnostic workup of lesions in the pharynx and larynx, from an examination with biopsy under general anesthesia to an office-based examination with flexible endoscopic biopsy under topical anesthesia. Procedural complications were evaluated to assess the safety of office-based flexible endoscopic biopsy in patients with benign and malignant laryngopharyngeal lesions. Patients who underwent flexible endoscopic biopsy from 2012 to 2016 were evaluated retrospectively. Complications were classified using the Clavien–Dindo classification of surgical complications. A total of 201 flexible endoscopic biopsies were performed in 187 patients. Two Clavien–Dindo grade I (laryngospasm and anterior epistaxis), one grade II (laryngeal bleeding), and one grade IIIb (laryngeal edema) complication were observed. The first complication was self-limiting and the other three required an intervention. All patients fully recovered without sequelae. Flexible endoscopic biopsy appears to be a safe office-based procedure for the diagnosis of benign and malignant laryngopharyngeal lesions.

Pediatric Videonasoendoscopy for Speech and Voice Evaluation

Many otolaryngologists and speech clinicians have found videofiberoptic evaluations to be invaluable for assessment of velopharyngeal and laryngeal function in adults. However, many professionals question the feasibility of routine use of these procedures in the pediatric population. This article describes a method for successful completion of videonasoendoscopic speech and voice evaluations of children as young as 3 years of age. The importance of the ENT/speech team is emphasized in both the collection and interpretation of data. In addition, contributions of videonasoendoscopic observations to diagnosis, medical treatment, and therapy for speech and voice disorders are discussed.

The effect of endoscopic sheaths on visualization in distal chip and fiberoptic laryngoscopy

Endoscopic sheaths covering the laryngoscope are advised to prevent cross contamination, but might hamper visualization as the most important tool in the diagnostic approach of laryngeal disease. We evaluated whether endoscopic sheaths change image quality and diagnostic accuracy of flexible distal chip laryngoscopy (DCL) and flexible fiberoptic laryngoscopy (FOL). Twelve healthy volunteers underwent a flexible laryngoscopy using a distal chip and a fiberoptic laryngoscope with and without endoscopic sheaths, and in this way 48 images were collected. To determine diagnostic accuracy, the 48 images were mixed with images of 40 patients. All images were randomly shown to four experts in the field of laryngology and head and neck oncology. Observers were asked to validate image quality, choose a diagnosis, and express their confidence level of that diagnosis. Image quality was validated better in DCL as compared to FOL (p < 0.05) both with or without endoscopic sheaths. Endoscopic sheaths worsened image quality in DCL (p < 0.05) but not in FOL. No differences were observed between DCL and FOL with or without endoscopic sheaths in diagnostic accuracy (79-89%). Confidence levels (7.7-8.1) were comparable in DCL and FOL and not influenced by endoscopic sheaths. Image quality in DCL is superior to FOL, but significantly hampered by the use of endoscopic sheaths. In FOL the image quality is already low and not further diminished by endoscopic sheaths.

Distal chip versus fiberoptic laryngoscopy using endoscopic sheaths: diagnostic accuracy and image quality

Laryngeal visualization is the hallmark in the diagnostic approach of laryngeal disease. In addition to fiberoptic techniques, digital distal chip technology has been developed to improve visualization. Endoscopic sheaths are used in daily clinical practice to prevent cross-contamination. The objective of the study was to evaluate diagnostic accuracy, image quality and interrater reliability of both flexible distal chip laryngoscopy (DCL) and flexible fiberoptic laryngoscopy (FOL) using contamination preventing endoscopic sheaths. In 53 cases both DCL and FOL images were collected during routine examination using endoscopic sheaths. All images were randomly shown to four experts in the field of laryngology and head and neck oncology. Observers were asked to choose a diagnosis, express their confidence level of that diagnosis and validate image quality: in this way 420 observations (four observers using two techniques) were analyzed. Accuracy in detecting laryngeal disease was 78 % (both DCL and FOL). Confidence level of diagnosis tended to be higher in DCL (p = 0.05). Image quality was validated better in DCL as compared to FOL (p < 0.05). Interrater agreement in identifying laryngeal disease was 1.5 times higher in DCL (κ = 0.44) as compared to FOL (κ = 0.29). In this study, reflecting daily clinical setting using sheathed endoscopes, DCL is identical to FOL regarding diagnostic accuracy, but DCL is superior to FOL in image quality and interrater reliability.

Functional voice disorders and their occurrence in 100 patients of hoarseness as seen on fibreoptic laryngoscopy

During a six month period, one hundred patients presenting with the primary complaint of hoarseness, in the out- patients department of otolaryngology at Safdarjung Hospital New Delhi were taken up fot the study Fach patient after being subjected to a detailed history- taking and examination, including a Fibreoptic Laryngoscopy was then put into one of ten categories on the basis of the ultimate diagnosis Functional voice disorders, forming the largest category with 51%, included lesions such as vocal nodules and polyps, which are secondary to vocal abuse A detailed study of the various types of functional voice disorders along with factors such as male female ratio and associated contributory factors was done the efficacy of the Fibreoptic laryngoscope as a diagnostic tool was also assessed.

Voice Change Following Thyroid and Parathyroid Surgery

Voice complications following thyroid and parathyroid procedures have long been recognized in the literature. However, there is little clear data on the nature, severity, and duration of any changes. No single previous study has comprehensively addressed the multiple issues involved. Most studies have been retrospective, preventing control over extraneous variables, or are small prospective studies using limited assessment measures. Emphasis has been on damage (paralysis) to the recurrent laryngeal nerve (RLN). The effects of surgery on the more subtle (but equally important) aspects of voice disorders have received little attention. This prospective study of 67 participants used multidimensional voice outcomes measures to assess changes in voice following thyroid and parathyroid surgery. Strict exclusion criteria minimized the effects of extraneous variables. Participants were assessed preoperatively to establish a baseline and at least twice more postoperatively. Generally speaking, the patient vocal performance and expert perceptual rating data suggest an incidence of 0% for all operation types. Mild changes at the early postoperative stages had settled in all cases by the 3-month postoperative assessment. Videostroboscopic evaluation revealed an interesting picture of six patients who appeared to have improved vocal function postsurgery, 15 patients who showed signs of neurological damage at their first postoperative examination, and only five "permanent" RLN paralyses at 12 months postsurgery. The potential for improvement in voice quality postsurgery has not previously been reported in the literature as far as we are aware. Symptoms consistent with RLN and superior laryngeal nerve palsy were present both pre- and postoperatively. Apparent nerve damage did not necessarily result in dysphonia. The potential for undiagnosed nerve damage preoperatively has rarely been reported in the literature. These results may have medico-legal implications, in addition to influencing surgical risk management and informed patient consent.

Correlation of glottal closure using concurrent ultrasonography and nasolaryngoscopy in children: a novel approach to evaluate glottal status

OBJECTIVES

Endoscopic procedures to assess aerodigestive symptoms by evaluating glottal motion are not practical in neonates because of small nares, respiratory difficulties, or additional stress. Our objective was to determine the temporal correlation between concurrent nasolaryngoscopy (NLS) and ultrasonography (USG) evaluation of glottal motion.

METHODS

Simultaneous USG of the glottis was performed in 10 subjects (5 males, 5 females, age = 4.5 months to 7.1 years) that underwent diagnostic flexible outpatient NLS. The USG transducer was placed on the anterior neck at the level of the vocal cords. The video signals from NLS and USG were integrated and synchronized into real-time cine loops of 1-min duration.

RESULTS

Frame-by-frame evaluation of 10,800 frames identifying glottal opening and closure time was compared between the two modalities by three observers and the timing of glottal closure was marked. Two investigators, blinded to NLS images, identified ultrasonographically determined glottal closure with 99% and 100% accuracy, and the mean probability of missing a closure frame was 0.007 (95% CI = 0.0008-0.024).

CONCLUSIONS

Temporal characteristics of glottal motion can be quantified by USG with perfect reliability and safety. This method can be useful in measuring the presence and the duration of laryngeal adduction.

Role of early voice therapy in patients affected by unilateral vocal fold paralysis

Objective:

To evaluate the functional results obtained after voice therapy in patients with unilateral vocal fold paralysis caused by different aetiologies.

Design:

Prospective analysis of the outcome of unilateral vocal fold paralysis cases treated at our speech and language rehabilitation service from November 2003 to January 2006. Thirty cases underwent behavioural treatment, between two and six weeks after unilateral vocal fold paralysis onset. A multi-dimensional assessment was carried out before, immediately after and six months after treatment.

Results:

After behavioural therapy, the prevalence of complete glottal closure increased significantly (p < 0.05). Subjects' pre-therapy mean values for jitter, shimmer and noise-to-harmonic ratio were statistically significantly different from those taken both immediately and six months after treatment (p < 0.05). The mean values for voice turbulence index significantly improved only six months after therapy (0.08 vs 0.04). At both post-treatment assessments, voice range profile analysis showed a significant decrease of lowest voice frequency and a significant increase of the number of semitones (p < 0.05). Mean values for grade, instability, breathiness, asthenia and voice handicap index scores were significantly decreased both immediately and six months after treatment, compared with pre-treatment values (p < 0.05).

Conclusions:

Early voice therapy may enable significant improvement in vocal function, allowing the patient to avoid surgery.

Evaluating the effectiveness and efficiency of voice therapy using transnasal flexible laryngoscopy: a randomized controlled trial

Transnasal flexible laryngoscopy (TFL) is an examination of laryngeal anatomy and physiology using continuous light. TFL is being used increasingly by voice pathologists in treatment but with little scientific evidence to support it. The purpose of this study was to evaluate the effectiveness and efficiency of TFL as a therapeutic tool. The study used a prospective randomized controlled trial. Fifty dysphonic subjects were recruited and randomly assigned to either a traditional treatment group or a TFL-assisted treatment group. The effectiveness of voice therapy in both treatment groups was measured with a package of voice outcome measures. Subjects in both treatment groups demonstrated statistically significant improvements after voice therapy (perceptual auditory rating of voice quality measurement p < 0.01; instrumental electroglottographic measurement p < 0.01; patient questionnaire measurement p < 0.01). The time taken to complete treatment in both groups was recorded. The average (median) time taken to complete voice therapy in the TFL-assisted treatment group was 2 hours less than in the traditional treatment group (p < 0.01). Voice therapy with TFL as a therapy tool was effective and more efficient than traditional voice therapy.

Hypopharyngeal Perforation Near-Miss During Transesophageal Echocardiography

OBJECTIVES/HYPOTHESIS

The traditional blind passage of a transesophageal echocardiography probe transorally through the hypopharynx is considered safe. Yet, severe hypopharyngeal complications during transesophageal echocardiography at several institutions led the authors to investigate whether traditional probe passage results in a greater incidence of hypopharyngeal injuries when compared with probe passage under direct visualization.

STUDY DESIGN

Randomized, prospective clinical study.

METHODS

In 159 consciously sedated adults referred for transesophageal echocardiography, the authors performed transesophageal echocardiography with concomitant transnasal videoendoscopic monitoring of the hypopharynx. Subjects were randomly assigned to receive traditional (blind) or experimental (optical) transesophageal echocardiography. The primary outcome measure was frequency of hypopharyngeal injuries (hypopharyngeal lacerations or hematomas), and the secondary outcome measure was number of hypopharyngeal contacts.

RESULTS

No perforation occurred with either technique. However, hypopharyngeal lacerations or hematomas occurred in 19 of 80 (23.8%) patients with the traditional technique (11 superficial lacerations of pyriform sinus, 1 laceration of pharynx, 12 arytenoid hematomas, 2 vocal fold hematomas, and 1 pyriform hematoma) and in 1 of 79 patients (1.3%) with the optical technique (superficial pyriform laceration) (P =.001). All traumatized patients underwent flexible laryngoscopy, but none required additional intervention. Respectively, hypopharyngeal contacts were more frequent with the traditional than with the optical technique at the pyriform sinus (70.0% vs. 10.1% [P =.001]), arytenoid (55.0% vs. 3.8% [P =.001]), and vocal fold (15.0% vs. 3.86% [P =.016]).

CONCLUSION

Optically guided trans-esophageal echocardiography results in significantly fewer hypopharyngeal injuries and fewer contacts than traditional, blind transesophageal echocardiography. The optically guided technique may result in decreased frequency of potentially significant complications and therefore in improved patient safety.

Voice therapy for vocal fold paralysis

There is no doubt that vocal fold paralysis is a debilitating condition affecting an individual's general health and quality of life. Optimal management of a patient with vocal fold dysfunction by an otolaryngologist, speech scientist, and speech language pathologist results in detailed objective videostroboscopic evaluation of glottal configuration during phonation, acoustic and aerodynamic measures, laryngeal EMG (if appropriate), and the patient's self-rating of vocal disability. Profound glottal incompetence is typically managed surgically with a few voice therapy sessions after surgery to ensure optimal vocal function. Patients with more adequate glottal closure are often seen for voice therapy and lost to follow-up when their voices improve enough to satisfy their vocal needs. It is essential that a complete battery of assessments, including perceptual, aerodynamic, acoustic, and stroboscopic measures, be obtained at periodic intervals in surgical and nonsurgical patients so as to evaluate vocal function over time. One of the few rigorous studies of perceptual, acoustic, aerodynamic, and videofiberscopic findings in patients after medialization with fat and thyroplasty assessed patients before surgery and at short (1-3 months),middle (4-6 months), and long (7-12 months) intervals after surgery. Improvement in most parameters at short- and long-term intervals was noted but not in the middle interval. The best results were obtained in women. Continued difficulty in increasing and maintaining subglottal pressure for high-intensity phonation was observed in both male and female patients. This fine study raises a number of questions as follows. What objective phonatory measures should be assessed before and after intervention and at what time intervals? Why were the women's results better than the men's results when no correlation of age, pulmonary function, or severity of preoperative voice and aerodynamic impairment was observed? Should voice therapy be initiated at the 4- to 6-month interval when voice quality diminished or within 1 to 2 months after surgery so that the decrement in vocal function might not occur? Why did vocal function ultimately improve after 7 to 12 months? Heuer et al and Colton and Casper found similar outcome satisfaction in patients electing surgery compared with those that were seen for voice therapy; however, the patients with lesser glottal incompetence in both studies opted for therapy. Can we better define vocal parameters that help to predict which patients may need surgery rather than therapy? Should all patients with high airflow measures but near-normal subglottal pressures and MPT greater than 10 seconds undergo 6 weeks of voice therapy rather than medical intervention? If all surgical patients were seen for 6 weeks of postoperative therapy, would voice satisfaction ratings increase to greater than 70%? Can we perceptively or objectively differentiate patients whose postoperative voices will be excellent from those whose voices will be merely adequate? These questions can only be answered by the development and implementation of a rigorous protocol studying women and men of varying ages with unilateral vocal fold paralysis choosing medialization surgery and electing voice therapy. Standardized assessments must include perceptual,aerodynamic, acoustic, stroboscopic, and patient satisfaction measures during soft- and loud-intensity tasks before and at periodic intervals after the two interventions.

Acoustic comparison of vowel articulation in normal and reverse phonation

Acoustic characteristics of the vowels /i,u,a/ produced by adult females and males during normal phonation were compared with the same vowels produced on deliberate ingressive airflow (i.e., "reverse" phonation). Results of the analysis revealed the average fundamental frequency (F0) of reverse phonation to be significantly higher than the corresponding normal phonations. There were no significant differences noted in the vocal tract resonance (F1 and F2 frequency) values for /i/ during normal and reverse phonation. However, the F1 values for /a/ were significantly lower, and the F2 values for /u/ significantly higher, during reverse phonation. The results are discussed with regard to differences in the articulatory control of the speech mechanism during reverse phonation as compared to normal expiratory phonation. Also discussed are the implications of using reverse phonation as a voice management technique.

The IPA categories "pharyngeal" and "epiglottal": laryngoscopic observations of pharyngeal articulations and larynx height

The phonetic problem is to describe accurately the articulatory mechanism, or mechanisms, responsible for the production of a series of sounds that are presently labelled on the chart of the International Phonetic Association as either pharyngeal or epiglottal. The sounds on which these categories are based are found in the Semitic languages, in the languages of the Caucasus, and in the languages of the Pacific Northwest coast of North America. In order to reconcile a variety of descriptive terms with a logical phonetic taxonomy, auditorily distinguishable parameters are deduced from a naturally occurring variety of sounds, isolated articulatorily, and observed with a fibreoptic laryngoscope to define a cardinal set of articulatory possibilities. Auditory comparisons with database illustrations of the sounds of various languages inform the production of cardinal values in the laryngoscopic study. Voiceless pharyngeals (fricatives) are identified by aryepiglottic fold constriction and a medial aperture. Voiced pharyngeals (approximants) are identified by aryepiglottic fold constriction and a covered glottis. Trilling can occur laterally along the aryepiglottic folds in either voiceless (fricative) or voiced (approximant) mode. A pharyngeal plosive is identified by full occlusion of the aryepiglottic sphincter. "Epiglottal" sounds, which have been described auditorily as "deeper" or "more extreme" than pharyngeals, are associated with either the trilled varieties of the simple fricative or approximant, or the default raised larynx posture of the aryepiglottic sphincter, with radical retraction of the tongue. They are therefore more severely constricted, but not physiologically "deeper" than simple [symbol: see text] or [symbol: see text]. Pharyngeal articulations may also be produced with larynx lowering. Voiceless pharyngeal [symbol: see text] may be accompanied by lowering of the larynx to distinguish it from a larynx-raised [H] variant. Larynx height variations are also found in "tense/lax" register distinctions.

Stroboscopic and acoustic measures of inspiratory phonation

Inspiratory phonation (IP) is the production of voice as air is taken into the lungs. Although IP is promoted as a laryngeal assessment and voice treatment technique, it has been described quantitatively in very few speakers. This study quantified changes in laryngeal adduction, fundamental frequency, and intensity during IP relative to expiratory phonation (EP). We hypothesized that IP would increase laryngeal abduction and fundamental frequency. The experiment was a within-subjects, repeated measures design with each subject serving as her own control. Participants were 10 females (ages 19-50 years) who underwent simultaneous transoral videostrobolaryngoscopy and acoustic voice recording. We found that membranous vocal fold contact decreased significantly during IP relative to EP, while the trends for change of ventricular fold squeeze during IP varied across individuals. Vocal fundamental frequency increased significantly during IP relative to EP, but intensity did not vary consistently across conditions. Without teaching or coaching, changes that occurred during IP did not carry over to EP produced immediately following IP within the same respiratory cycle.

Effects of laryngeal endoscopy on the vocal performance of young adult females with normal voices

This study investigated changes in maximum phonation time and acoustic and perceptual measures of voice following topical anesthesia and laryngeal endoscopy with the flexible endoscope. Forty-four females, aged 18-33 years and with normal voices, performed four vocal tasks: (a) 3-second /i/ prolongation, (b) maximum phonation time on /i/, (c) stepwise scale-singing, and (d) reading a standard passage. Subjects performed these tasks prior to anesthesia, after anesthesia, and again during laryngeal endoscopy. Voice samples were analyzed forjitter, shimmer, harmonic-to-noise ratio, speaking fundamental frequency, maximum phonational frequency range, maximum phonation time, harshness, and breathiness. Results demonstrated significant reductions in maximum phonational frequency range following anesthesia and, during laryngeal endoscopy, reductions in maximum phonation time and increases in speaking fundamental frequency, minimum fundamental frequency on scale-singing, and breathiness. Clinicians using laryngeal endoscopy for evaluation and management of vocal dysfunction should, therefore, consider the possible effects of these procedures on vocal functioning.

A prospective, double-blind, randomized study on the use of a topical anesthetic, vasoconstrictor, and placebo during transnasal flexible fiberoptic endoscopy

The purpose of the present study was to compare patient comfort levels following administration of a topical anesthetic, vasoconstrictor, placebo, or nothing to the nasal mucosa prior to flexible fiberoptic transnasal endoscopy. Using a prospective, double-blind, randomized design, 152 consecutive patients were randomly assigned to receive a topical anesthetic (N = 54), vasoconstrictor (N = 50), or placebo (N = 48). No significant differences were found among the three variables. An additional 50 consecutive patients had endoscopy performed without administration of any substance to the nares, and no significant differences were found among the four variables (N = 202). It was concluded that speech-language pathologists can perform independent and comfortable transnasal endoscopy without administration of any substance to the nasal mucosa. Flexible fiberoptic endoscopy, however, should be performed by experienced clinicians with care taken to examine visually the patency of both nares for ease and comfort of scope insertion.

Role of ultrasound in the assessment of vocal cord function in infants and children

The determination of the cause of stridor in the infant and child is an important directive for the otolaryngologist. The limitations of current clinical diagnostic techniques have provided the impetus for pursuing newer, more practical techniques to diagnose vocal cord paralysis in children. The purpose of this paper is to describe a new technique to image the larynx and determine its role in discerning vocal cord paralysis in children. This study began with an animal study (lamb model) demonstrating that computerized ultrasound can accurately delineate laryngeal anatomy and function. The human protocol included 27 patients (age 1 day to 14 years): 15 with normal larynges and 12 with vocal cord paralysis. Recorded ultrasound studies of these subjects were compiled in a randomly ordered videotape and presented twice and viewed in a blinded manner by four expert raters. Statistical analysis of their readings revealed that ultrasound is a highly accurate technique to document vocal cord paralysis, with a high degree of interrater and intrarater reliability. Beyond the accuracy and consistency of computerized ultrasound, there are many other aspects of this technique that make it clinically attractive. Laryngeal ultrasound is noninvasive, painless, and widely accepted. It is relatively safe, with no radiation exposure and no need for sedation or anesthesia. It is well tolerated by patients and their families. The results are easily displayed and recorded and available for hard copy storage. This investigation should not be interpreted as an endorsement for laryngeal ultrasound as a replacement for endoscopy in children. This work does indicate, however, that ultrasound is a technique that can accurately address the special issue of vocal cord mobility in infants and children. At present, this is the primary use for laryngeal ultrasound, although with additional investigation and sophistication it is likely that ultrasound of the larynx may become useful for other purposes.

Laryngeal image biofeedback

The proper treatment of many voice disorder patients includes modification of voice production. Laryngeal image biofeedback (LIB), a new technique to help selected patients modify vocal fold posture and thereby vocal production is described. The effectiveness of this technique as a learning tool is assessed in 20 subjects.

Pediatric videonasoendoscopy for speech and voice evaluation

Many otolaryngologists and speech clinicians have found videofiberoptic evaluations to be invaluable for assessment of velopharyngeal and laryngeal function in adults. However, many professionals question the feasibility of routine use of these procedures in the pediatric population. This article describes a method for successful completion of videonasoendoscopic speech and voice evaluations of children as young as 3 years of age. The importance of the ENT/speech team is emphasized in both the collection and interpretation of data. In addition, contributions of videonasoendoscopic observations to diagnosis, medical treatment, and therapy for speech and voice disorders are discussed.

The flexible fibreoptic rhinolaryngoscope

An accurate, reliable, inexpensive and safe method for the examination of the upper aero-digestive tract is described. Its efficacy is evaluated retrospectively on 250 patients over an 18-month period.

Significance of the use of endoscopes in the management of head and neck tumors

The advancement of the endoscope and its related technology has made it easy to apply them to the management of head and neck tumors at the level of the everyday clinic not only in the diagnostic aspect but also for therapeutic purposes. In the diagnostic aspect, endoscopic procedure will contribute to early diagnosis, precise comprehension of extension, and appropriate biopsy of tumors. Accurate follow-up study and laser surgical procedures using Nd-YAG laser may be other therapeutic contributions. X-ray examinations including CT should always be complementary measures to this procedure. It is extremely important to detect earlier the presence of malignancy. The appropriate use of endoscopes in the management of head and neck tumors will help to improve the results of treatment, because one of the greatest reasons for poor prognosis in nasopharyngeal, hypopharyngeal, cervical esophageal, ethmoidal, and sphenoidal cancers is attributed to the difficulty of early detection.

Videolaryngoscopy. A comparison of fiberscopic and telescopic documentation

Videolaryngoscopy is a most useful and effective method of evaluation and documentation of physiological and pathological conditions of the larynx. It is of great value for making accurate diagnosis and planning proper treatment. It permits instant and simultaneous voice and video recording and later analysis. Videolaryngoscopy can be accomplished with either a flexible fiberscope or a rigid right-angled telescope. Fiberscopic videolaryngoscopy is more useful for voice analysis of speech disorders and evaluation of such functions of the larynx as phonation, singing, and swallowing. Telescopic videolaryngoscopy is superior for critical evaluation of anatomical and pathological changes of the laryngeal structures as well as close-up examination of vocal cord function. While fiberscopic laryngoscopy is technically easy, fiberscopic video documentation is much more difficult than telescopic video documentation. Telescopic videolaryngoscopy provides clearer and sharper images of the larynx. Advantages and disadvantages of each method are discussed.

The speech clinician's use of fiberoptics in indirect laryngoscopy

This paper explores the use of fiberoptics in indirect laryngoscopy and encourages the speech pathologist to use this procedure in a diagnostic and therapeutic context. Routine use of this procedure by speech pathologists would broaden the role definition of the voice clinician as a skilled evaluator of vocal-fold pathologies.