A Novel Gel Pad Laryngeal Ultrasound for Vocal Cord Evaluation

Surgeon-performed transcutaneous laryngeal ultrasound for vocal cord assessment after total thyroidectomy: a prospective study : Original article

PURPOSE

Assessing vocal cord mobility is crucial for patients undergoing thyroid surgery. We aimed to evaluate the feasibility and efficacy of surgeon-performed transcutaneous laryngeal ultrasound (TLUS) compared to flexible nasolaryngoscopy.

METHOD

From February 2022 to December 2022, we conducted a prospective observational study on patients scheduled for total thyroidectomy at our Institution. All patients underwent TLUS followed by flexible nasolaryngoscopy by a blinded otolaryngologist. Findings were classified as normal or vocal cord movement impairment and then compared. Patients evaluable on TLUS were included in Group A, while those not evaluable were included in Group B, and their features were compared.

RESULTS

Group A included 180 patients, while Group B included 21 patients. Male sex (p < 0.001), age (p = 0.034), BMI (p < 0.001), thyroid volume (p = 0.038), and neck circumference (p < 0.001) were associated with Group B. TLUS showed a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 100%, 99.4%, 94.4%, 100%, and 99.4%, respectively. Cohen's K value was 0.984.

CONCLUSION

TLUS is a valid, easy-to-perform, non-invasive, and painless alternative for evaluating vocal cords in selected patients. It can be used either as a first level exam and as screening tool for selecting cases for flexible nasolaryngoscopy. TLUS should be integrated into routine thyroid ultrasound examination.

The effect of gel pads on the measurement of breast superficial lesions by shear wave elastography

OBJECTIVE

This study aimed to compare the repeatability and diagnostic efficiency of shear wave elastography (SWE) while using coupling gel and gel pads in the diagnosis of superficial breast lesions.

METHODS

Two experienced sonographers, trained in SWE, used different methods to perform the maximum Young's modulus (Emax) measurement of the lesion while using coupling gel SWE and gel pad SWE at different time points. All 80 lesions were in the superficial layer of the breast. The interclass correlation coefficient (ICC) was calculated to evaluate the intraobserver and interobserver repeatability. Meanwhile, the receiver operating characteristic curve (ROC curve) was used to calculate the sensitivity, specificity and area under the curve of the two methods.

RESULTS

In the 80 breast lesions, the intraobserver and interobserver reproducibility of SWE measurements using coupling gel were considered good, and the ICCs were 0.728 (95% CI: 0.509-0.813) and 0.702 (95% CI: 0.492-0.795), respectively. The intraobserver and interobserver reproducibility of the SWE measured by the gel pad were also considered good, and the ICCs were 0.745 (95% CI: 0.501-0.801) and 0.713 (95% CI: 0.498-0.802), respectively. The sensitivity, specificity and area under the curve were 0.711 and 0.737, 0.929 and 0.905, and 0.873 and 0.878, respectively.

CONCLUSIONS

In the SWE measurement of superficial breast lesions, the use of a gel pad does not affect the repeatability and diagnostic efficiency of the measurement.

Can Transcutaneous Laryngeal Ultrasonography Systematically Quantify Vocal Fold Movement?-A Feasibility Study

OBJECTIVES

Several studies have assessed adult vocal fold movement using transcutaneous laryngeal ultrasonography (TLUSG) during the perioperative period of thyroidectomy. However, the movement was not objectively quantified. This study aimed to provide a feasible and objective method for assessing vocal fold movement using TLUSG.

STUDY DESIGN

Feasibility study.

METHODS

TLUSG was performed during calm breathing and breath-holding in healthy adult volunteers. The morphology and anatomy of the larynx were observed and measured using an ultrasonic self-contained measurement function. At the end of the calm inspiratory and breath-holding phases, vocal fold angle, vocal fold length, distance from vocal process to the midline, distance from anterior vocal commissure to arytenoid cartilage, distance from false vocal fold to the midline, and distance from the anterior horn of thyroid cartilage to false vocal fold were measured. Data were analyzed using a t test (significance <0.05).

RESULTS

The ultrasonic images were satisfactory in all 40 healthy adult volunteers (age 19-35 years; body mass index 18.55-23.93 kg/m2; 20 men and 20 women). There were no significant differences in all laryngeal parameters between the left and right sides in both phases (P > 0.05). Moreover, all differences in laryngeal parameters between the end of the calm inspiratory phase and the breath-holding phase were statistically significant (P < 0.05), regardless of sex.

CONCLUSION

The relevant positional parameters of the vocal fold, arytenoid cartilage, and false vocal fold and their differences before and after vocal fold movement in healthy adult volunteers can be obtained objectively using TLUSG.

Normative data for certain vocal fold biomarkers among young normophonic adults using ultrasonography

PURPOSE

The current study aimed to profile vocal fold morphology, vocal fold symmetry, gender and task-specific data for vocal fold length (VFL) and vocal fold displacement velocity (VFDV) in young normophonic adults in the age range of 18-30 years using ultrasonography (USG).

METHODS

Participants underwent USG across quiet breathing, /a/ phonation and /i/ phonation tasks, and acoustic analysis was conducted to explore the relationship between USG and acoustic measures.

RESULTS

The study found that males have longer vocal folds than females, and overall greater velocities were observed in /a/ phonation, followed by /i/ phonation, with the lowest velocity observed in the quiet breathing task.

CONCLUSIONS

The obtained norms can be used as a quantitative benchmark for analyzing the vocal fold behavior in young adults.

Quasi-static ultrasound elastography of ex-vivo porcine vocal folds during passive elongation and adduction

OBJECTIVES

The elastic properties of the vocal folds have great influence on the primary sound and thus on the entire subsequent phonation process. Muscle contractions in the larynx can alter the elastic properties of the vocal fold tissue. Quasi-static ultrasound elastography is a non-destructive examination method that can be applied to ex-vivo vocal folds. In this work, porcine vocal folds were passively elongated and adducted and the changes of the elastic properties due to that manipulations were measured.

METHODS

Manipulations were performed by applying force to sewn-in sutures. Elongation was achieved by a suture attached to the thyroid cartilage, which was pulled forward by defined weights. Adduction was effected by two sutures exerting torque on the arytenoid cartilage. A series of ten specimens was examined and evaluated using a quasi-static elastography algorithm. In addition, the surface stretch was measured optically using tattooed reference points.

RESULTS

This study showed that the expected stiffening of the tissue during the manipulations can be measured using quasi-static ultrasound elastography. The measured effect of elongation and adduction, both of which result in stretching of the tissue, is stiffening. However, the relative change of specific manipulations is not the same for the same load on different larynges, but is rather related to stretch caused and other uninvestigated factors.

CONCLUSION

The passive elongation and adduction of vocal folds stiffen the tissue of the vocal folds and can be measured using ultrasound elastography.

Laryngeal Ultrasound Detects Vocal Fold Immobility in Adults: A Systematic Review

Laryngeal ultrasound (US) is becoming widely accepted for assessing true vocal fold immobility (TVFI), a potential complication of laryngeal and thyroid surgery. The objective of this project is to perform a systematic review and meta-analysis of pooled evidence surrounding laryngeal US as a modality for diagnosing TVFI in adults at risk for the condition in comparison to laryngoscopy as a gold standard. Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations from January 1, 2000, to June 30, 2020. Studies were included if they involved patients 16 years and older, where laryngeal US was compared to laryngoscopy for TVFI. Studies were excluded if there were insufficient data to compute a sensitivity/specificity table after attempting to contact the authors. Case reports, and case series were also excluded. The initial search returned 1357 citations. Of these, 109 were selected for review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty citations describing 6033 patients were included in the final meta-analysis. A bivariate random effects meta-analysis was performed, revealing a pooled sensitivity for laryngeal US of 0.95 (95% confidence interval [CI] 0.88-0.98), a specificity of 0.99 (95% CI 0.97-0.99), and a diagnostic odds ratio of 1328.2 (95% CI 294.0-5996.5). The area under the curve of the hierarchical summary receiver operating characteristic curve was 0.99 (95% CI 0.98-1.00). Laryngeal US demonstrates high sensitivity and specificity for detecting VFI in the hands of clinicians directly providing care to patients.

Translaryngeal ultrasound in thyroid surgery: state of the art review

BACKGROUND

Clinical voice assessment prior to thyroid and parathyroid surgery is essential, but the paradigm of indirect laryngoscopy (IDL), when indicated, has been challenged by the risk of aerosolised SARS-Cov-2 during endoscopy of the aerodigestive tract. Translaryngeal ultrasound (TLUS) to assess the vocal cords has been proposed as a safe, non-invasive and sensitive alternative. The aim of this review was to verify TLUS as a viable tool for perioperative laryngeal assessment.

METHOD

A literature review was performed using Medline, Embase, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials and Scopus with the following search strategy: (vocal cord OR vocal fold OR glottic OR glottis OR vocal ligaments OR rima glottidis) AND (ultras* OR sonograph* OR echography OR echotomography).

RESULTS

Fifteen studies were included in this review. All studies compared TLUS to IDL in visualizing the vocal cords in adults. Ten studies compared pre-operative TLUS to IDL where 50.6-100% of vocal cords were successfully visualized. Nine studies compared post-operative TLUS to IDL and reported visualization between 39.6% and 100%. Pre- and post-operative negative predictive values ranged from 60% to 100%.

CONCLUSION

Whilst promising, successful visualization of the cords is limited by inter-user variability, older age and male gender. Thus, we see the role of TLUS as an alternative to IDL in the post-operative setting in the young patient following uncomplicated surgery with a normal voice on clinical examination, to confirm recurrent laryngeal nerve integrity while minimizing the risk of aerosolization.

Transcutaneous Laryngeal Ultrasound for Vocal Cord Paralysis Assessment in Patients Undergoing Thyroid and Parathyroid Surgery-A Systematic Review and Meta-Analysis

Recurrent laryngeal nerve injury is an important complication following thyroid and parathyroid surgery. Recently, Transcutaneous laryngeal ultrasound (TLUSG) has emerged as a non-invasive alternative to laryngoscopic examination for vocal cord (VC) assessment. The aim of the systematic review and meta-analysis was to determine its diagnostic accuracy in reference to laryngoscopy. It was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. MEDLINE, Scopus, Cochrane library and Web of Science databases were searched to identify relevant articles. Sixteen studies were included in the review. Pooled diagnostic accuracy was calculated based on weighted arithmetic mean and plotting forest plot. The pooled visualization rate was 86.28% and 94.13% preoperatively and postoperatively, respectively. The respective pooled sensitivity and specificity was 78.48% and 98.28%, and 83.96% (CI 95%: 77.24-88.50%) and 96.15% (CI 95%: 95.24-96.88%). The diagnostic accuracy improved if transverse and lateral approaches, and valsalva maneuver were utilized. Male gender and older age were the most crucial risk factors for VC non-visualization. TLUSG is an efficacious screening tool for vocal cord palsy due to its high sensitivity. It is likely to prevent unnecessary laryngoscopic examination in around 80% of patients, with the potential for becoming a gold standard for specific (female/young) patient cohort through assimilative modifications use, increasing expertise and development of objective measurements in the future.

A Simple Tool to Improve Visualization of the Vocal Cords on Translaryngeal Ultrasound in Male Patients

INTRODUCTION

Laryngeal ultrasound has been increasingly used for the evaluation of the vocal cords mobility after thyroid and parathyroid surgery. The sensitivity and positive predictive value of the method are reported to be higher than 80%. Nevertheless, the visualization rate in male patients remains low; therefore, ultrasound is not attractive for the perioperative workup in those patients. In the present study, we evaluate the ability to improve the visualization rate for male patients by using a gel pad as an interface between the skin and the ultrasound probe.

METHODS AND MATERIALS

Between December 2018 and January 2019, 92 male patients (mean age 49 years; range: 20-80 years) referred to our hospital with different thyroid pathologies received a laryngeal ultrasound without (TLUS) and subsequently with gel pad (G-TLUS). TLUS was performed by B-scan (probe 5-13 MHz, aperture 40 mm). The data were prospectively collected and statistically analyzed.

RESULTS

The visualization rate in the TLUS group was 35% (32 out of 92 patients). The use of the gel pad could increase the rate to 78% (p < 0.0001). For both groups, visualization rates are lower in older patients (> 50 years) compared to younger individuals (TLUS: 25% vs. 45%, p < 0.05; G-TLUS: 75% vs 82%, p = 0.45).

CONCLUSION

The gel pad significantly improves the vocal cord visualization rate in male patients and should be used routinely.

Laryngeal Evaluation during the COVID-19 Pandemic: Transcervical Laryngeal Ultrasonography

The novel coronavirus disease (COVID-19), caused by the SARS-CoV-2 virus, has quickly become a global pandemic since its initial outbreak in China in late 2019. Institutions are faced with the challenge of upholding the standard of care while maintaining safety for health care personnel and patients. Due to the common performance of aerosol-generating endoscopic procedures in the upper respiratory tract, otolaryngologists are at uniquely high risk for potential infection. When possible, alternative diagnostic and treatment strategies should be pursued. For patients suspected of having functional laryngeal abnormalities, transcervical laryngeal ultrasound provides a rapid and noninvasive evaluation of vocal fold motion to inform decisions about safety of feeding, airway, and progression of care.

The surgical management of primary hyperparathyroidism: an updated review

Patients with primary hyperparathyroidism often present clinically asymptomatic with various biochemical compositions of serum calcium, parathyroid hormone, vitamin D and urinary calcium. Understanding the subtle differences in clinical and biochemical presentations is key for timely diagnosis and referral to an experienced parathyroid surgeon. Surgery remains the only option for cure of primary hyperparathyroidism, which now favors a directed parathyroidectomy with intra-operative adjuncts. However it is important to understand and revise the surgical approach for patients with hereditary conditions or nonlocalizing studies. Revised guidelines from the Fourth International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism in 2013 and the American Association of Endocrine Surgeons in 2016 are reviewed in this paper for an updated review of this condition.