Identifying the Prevalence of Dysphagia among Patients Diagnosed with Unilateral Vocal Fold Immobility

Dysphagia as a predictor of voice handicap and voice restoration in unilateral vocal fold immobility

OBJECTIVE

Dysphagia is multifactorial in unilateral vocal fold immobility (UVFI). Severe dysphagia could indicate greater functional deficits in UVFI. The purpose of this study is to evaluate the association of dysphagia with the need for surgical voice restoration in patients with UVFI.

STUDY DESIGN

Retrospective chart review.

SETTING

Single-institution, tertiary referral center.

METHODS

Records of UVFI patients from 2008 to 2018 were examined. Dysphagia severity was extracted from patient history. Etiology of UVFI and other relevant variables were analyzed to determine their association with dysphagia. Dysphagia severity and other clinical variables were then analyzed for their association with surgical voice restoration.

RESULTS

Eighty patients met selection criteria out of 478 patients with UVFI. There was significant concordance between dysphagia severity extracted from patient history and patient-reported EAT-10 scores (R = 0.59, p = 0.000035). Patients' EAT-10 scores were correlated with VHI-10 scores (R = 0.45, p = 0.011). Severe dysphagia (p = 0.037), high VHI-10 score on presentation (p = 0.0009), and longer duration of hoarseness before presentation (p = 0.008) were associated with surgical voice restoration in UVFI patients.

CONCLUSION

In this pilot study, severe dysphagia and increased voice handicap on presentation were associated with the need for surgical voice restoration in UVFI patients. Presenting dysphagia may be an additional variable for clinicians to consider for management of UVFI.

Analysis of Dysphagia and Cough Strength in Patients with Unilateral Vocal Fold Paralysis

The association between swallowing function and cough strength in patients with unilateral vocal fold paralysis (UVFP) is unknown. We evaluated the relationship between voluntary cough strength and dysphagia among patients with UVFP (UVFP group) by comparing their data with that of corresponding healthy participants (healthy control [HC] group) in a prospective observational study. From February 1st, 2018 to March 30th, 2019, we recruited patients with a voice disorder due to UVFP, who were referred to our university hospital. Patients with a history of laryngeal surgery, vagal nerve paralysis, or cardiac and respiratory failure were excluded. Descriptive and clinical data regarding swallowing, voice, and cough peak flow (CPF) were collected as a measure of cough strength. The UVFP group comprised six women and seven men (median age, 68.0 years), and the HC group comprised six women and eight men (median age 65.5 years). The groups differed significantly in the Eating Assessment Tool (EAT)-10 scores and CPF rates (P < 0.001). Among patients with UVFP, 84.6% had an abnormal EAT-10 score of ≥ 3. Additionally, 16.7% of the patients exhibited liquid aspiration with contrast medium on a videofluorographic swallowing study (VFSS). There was no correlation between the CPF values, EAT-10 scores, or the VFSS results. Therefore, patients with severe UVFP, whose condition had been fixed, had difficulties when swallowing (85% of cases), and some even presented with aspiration on VFSS (20% of cases), while receiving a regular diet.

Safety and effectiveness of vocal fold injection laryngoplasty in infants less than one year of age

INTRODUCTION

Injection laryngoplasty (IL) is commonly performed for unilateral vocal fold immobility (UVFI). However, the safety and efficacy in patients <1 year of age are not widely recognized. This study analyzes the safety and swallow outcomes in a cohort of patients <1 year who underwent IL.

METHODS

This retrospective analysis evaluated patients at a tertiary children's institution between 2015 and 2022. Patients were eligible if they underwent IL for UVFI and were <1 year at time of injection. Baseline characteristics, perioperative data, oral diet tolerance, and preoperative and postoperative swallow data were collected.

RESULTS

49 patients were included, 12 (24%) of whom were premature. The average age at injection was 3.9 months (SD 3.8), time from UVFI onset to injection 1.3 months (2.0), and weight at injection 4.8 kg (2.1). The baseline American Association of Anesthesiologists physical status classification scores were 2 (14%), 3 (61%), and 4 (24%). 89% of patients had improvements in objective swallow function postoperatively. Of the 35 patients who were preoperatively enterally-dependent and did not have medical circumstances precluding advancement to oral feeds, 32 (n = 91%) tolerated an oral diet postoperatively. There were no long-term sequelae. Two patients had intraoperative laryngospasm, one intraoperative bronchospasm, and one with subglottic and posterior glottic stenosis was intubated for <12 h for increased work of breathing.

CONCLUSIONS

IL is a safe and effective intervention that can reduce aspiration and improve diet in patients <1 year old. This procedure can be considered at institutions with the appropriate personnel, resources, and infrastructure.

3D VOSNet: Segmentation of endoscopic images of the larynx with subsequent generation of indicators

Video laryngoscope is available for visualizing the motion of vocal cords and aid in the assessment of analyzing the larynx-related lesion preliminarily. Laryngeal Electromyography (EMG) needs to be performed to diagnose the factors of vocal cord paralysis, which may cause patient feeling unwell. Thus, the problem is the lack of credible larynx indicators to evaluate larynx-related diseases in the department of otolaryngology. Therefore, this paper aims to propose a 3D VOSNet model, which has the characteristics of sequence segmentation to extract the time-series features in the video laryngoscope. The 3D VOSNet model can keep the time-series features of three images before and after of the specific image to achieve translation and occlusion invariance, which explicitly signifies that our model can segment and classify each item in the video of laryngoscopy not affected by extrinsic causes such as shaking or occlusion during laryngoscope. Numerical results revealed that the testing accuracy rates of the glottal, right vocal cord, and the left vocal cord are 89.91%, 94.63%, and 93.48%, respectively. Our proposed model can segment glottal and vocal cords from the sequence of laryngoscopy. Finally, using the proposed algorithm computes six larynx indicators, which are the area of the glottal, area of vocal cords, length of vocal cords, deviation of length of vocal cords, and symmetry of the vocal cords. In order to assist otolaryngologists in staying credible and objective when making decisions without any doubt during diagnosis and also explaining the clinical symptoms of the larynx such as vocal cord paralysis to patients after diagnosis, our proposed algorithm provides otolaryngologists with explainable indicators (X-indicators).

Impact on swallowing functions of arytenoid adduction in patients with unilateral vocal fold paralysis

OBJECTIVE

Although the pathophysiology of swallowing dysfunction in patients with unilateral vocal fold paralysis (UVFP) remains uncertain, glottal insufficiency is known to be a possible major cause, and other factors due to vagus nerve or recurrent laryngeal nerve damage may contribute to dysphagia or aspiration. This study aimed to evaluate the effect of arytenoid adduction (AA) surgery on the swallowing functions of UVFP patients and to investigate the important role of glottic closure during swallowing.

METHODS

We prospectively analyzed the data of thirteen patients with UVFP who underwent AA in combination with medialization laryngoplasty (ML) for improving voice quality. The subjects received a series of examinations for not only voice function but also swallowing function and cough strength both preoperatively and approximately 6 months after surgery. The evaluations of voice function included the Voice Handicap Index and aerodynamic measures; the evaluations of swallowing function included the Eating Assessment Tool-10, liquid aspiration, a videofluorographic examination of swallowing study, and high-resolution manometry; and the evaluation of cough strength included the measurement of cough peak flow. All measurements before and after surgery were statistically compared and examined.

RESULTS

Considerable improvements in voice measures were observed after the procedure, as sufficient glottic closure was achieved during phonation and swallowing. In terms of swallowing evaluation, there were significant differences in the subjective assessment methods after the operation. Additionally, our intervention improved two cases of aspiration according to abnormal findings on the videofluorographic examination of swallowing. There was a significant difference in cough peak flow, with all participants having better values after surgery. High-resolution manometry revealed no significant differences between pre- and postsurgery in any parameters at the level of the mesopharynx or upper esophageal sphincter.

CONCLUSION

The findings of our study suggest an important effect on the dysphagia of UVFP patients who undergo AA combined with ML. In addition, we revealed improvements in swallowing by strengthening incomplete glottic closure; thus, we consider that sufficient glottic closure must play an important role in swallowing function in patients with UVFP.

Dysphagia Outcomes Following Surgical Management of Unilateral Vocal Fold Immobility: A Systematic Review and Meta-analysis

OBJECTIVE

To assess dysphagia outcomes following surgical management of unilateral vocal fold immobility (UVFI) in adults.

DATA SOURCES

Ovid MEDLINE, Embase, Web of Science, and Cochrane Central.

REVIEW METHODS

A structured literature search was utilized, and a 2-researcher systematic review was performed following PRISMA guidelines. Extractable data were pooled, and a quantitative analysis was performed with a random effects model to analyze treatment outcome and complications by procedure.

RESULTS

A total of 416 publications were screened and 26 met inclusion criteria. Subjects encompassed 959 patients with UVFI who underwent 916 procedures (n = 547, injection laryngoplasty; n = 357, laryngeal framework surgery; n = 12, laryngeal reinnervation). An overall 615 were identified as having dysphagia as a result of UVFI and had individually extractable outcome data, which served as the basis for a quantitative meta-analysis. In general, dysphagia outcomes after all medialization procedures were strongly positive. Quantitative analysis demonstrated a success rate estimate of 90% (95% CI, 75%-100%) for injection laryngoplasty and 92% (95% CI, 87%-97%) for laryngeal framework surgery. The estimated complication rate was 7% (95% CI, 2%-13%) for injection laryngoplasty and 15% (95% CI, 10%-20%) for laryngeal framework surgery, with minor complications predominating. Although laryngeal reinnervation could not be assessed quantitatively due to low numbers, qualitative analysis demonstrated consistent benefit for a majority of patients for each procedure.

CONCLUSION

Dysphagia due to UVFI can be improved in a majority of patients with surgical procedures intended to improve glottal competence, with a low risk of complications. Injection laryngoplasty and laryngeal framework surgery appear to be efficacious and safe, and laryngeal reinnervation may be a promising new option for select patients.

Modified Arytenoid Adduction Operation for the Treatment of Unilateral Vocal Fold Paralysis

INTRODUCTION

Unilateral vocal fold paralysis (UVFP) was a relative common glottic insufficiency disease; however, a completely satisfactory treatment of UVFP was elusive. This study was aimed to evaluate the surgical efficacy of modified arytenoid adduction with fenestration of the thyroid cartilage in the management of patients with UVFP, including voice and aspiration outcomes, and to summarize the postoperative complications.

METHODS

A retrospective analysis was performed on a total of 21 patients who underwent modified arytenoid adduction operation with fenestration of the thyroid cartilage for UVFP from July 2012 to June 2017. The scores of Grade, Roughness, Breathiness, Asthenia, Strain scale (GRBAS), voice self-satisfaction, dynamic laryngoscopy and the voice acoustic data (fundamental frequency [F0], fundamental frequency perturbation [jitter], loudness, amplitude perturbation [shimmer], and maximal phonatory time [MPT], etc.) were statistically analyzed preoperatively and 3-6 months postoperatively. The occurrence of postoperative complications was also summarized.

RESULTS

The voice subjective perception of 21 patients was significantly improved after operation. The rate of voice self-satisfaction was 90.5%. The mean values of voice acoustics parameters were significantly improved. The MPT was significantly longer (p < 0.001), and the ratings of postoperative aspiration were significantly decreased compared with the preoperation. Among the 21 patients, 15 cases had sense of laryngeal obstruction, 8 cases had of 1-2° laryngemphraxis (recovered after 10-15 days). There were 2 cases of laryngeal stridor, 1 case of incision infection, 1 case of pharyngeal fistula, and 1 case of falsetto (corrected by voice training). No patient had laryngeal hematoma, neck hematoma, or laryngospasm.

CONCLUSION

The modified arytenoid adduction operation with fenestration of the thyroid cartilage can significantly improve the vocal function of patients with UVFP and effectively reduce the aspiration, with fewer postoperative complications, less trauma, and more convenient advantages.

Detecting Aspiration During FEES with Narrow Band Imaging in a Clinical Setting

The use of narrow band imaging (NBI) during flexible endoscopic evaluation of swallowing (FEES) is recognised as an emerging technology to improve the contrast of the test fluid during endoscopic dysphagia evaluation. This study tested the hypothesis that the use of NBI in FEES would improve the detection of laryngeal penetration and aspiration in patients with unilateral vocal fold paralysis/paresis (UVFP), a typically difficult population in which to detect the presence of aspiration with FEES. Twenty-one consecutive outpatients with UVFP were evaluated with FEES using white light (WL) and NBI under 150 test conditions (75 WL & 75 NBI). Three speech pathologists, highly experienced in FEES using WL but novices to using NBI, rated laryngeal penetration and aspiration for green dyed thin fluid (5 ml and 90 ml) and mildly thick fluid (5 ml) milk, and were compared to two raters more experienced in using NBI during FEES. Laryngeal penetration and aspiration were significantly higher for larger volumes (90 ml) (p < 0.05). With NBI-naïve raters, there was a trend towards lower intra-rater and inter-rater reliability compared to WL on all bolus trials reaching significance on mildly thick fluid (p < 0.01). There was lower rater confidence when using NBI compared to WL in NBI-naïve raters to detect aspiration (p < 0.01). Sensitivity was lower regardless of NBI experience; 80.77-84.21% with WL compared to 46.15-50.00% with NBI. Findings indicate that the improved contrast of a dyed opaque milk trial under WL may negate the potential benefits of using NBI to increase the contrast of the test fluid and supports the use of an opaque test fluid such as milk. NBI may also not be as useful to clinicians with no experience with the altered light condition, and can result in lower sensitivity in even the experienced user.

Physiology of Dysphagia in Those with Unilateral Vocal Fold Immobility

Quantitative measures of swallowing function were extracted from modified barium swallowing studies (MBS) to characterize swallowing pathophysiology in patients with unilateral vocal fold immobility (UVFI). All individuals with UVFI completing a MBS during the prior 5 years were included. Demographic information, penetration-aspiration score, timing of aspiration and quantitative measures from the MBS were extracted from electronic medical records and compared across 1, 3, and 20 cc liquid bolus swallows. UVFI patient measures were compared to normal age-matched controls to identify swallowing pathophysiology associated with aspiration. The incidence of aspiration by UVFI etiology groups (i.e., central nervous system, idiopathic, iatrogenic, skull base tumor, or peripheral tumor) was also compared. Of the 61 patients who met inclusion criteria, aspiration was observed in 23%. Maximum pharyngeal constriction was abnormal in 79% of aspirators compared to 34% of non-aspirators (p = .003). Delay in airway closure was the most common swallowing abnormality identified in the study population (62%) but was not associated with aspiration. Among the 14 individuals who aspirated, the iatrogenic and skull base tumor etiology groups comprised the majority (i.e., 36% each). However, the incidence of aspiration for the iatrogenic group was 19% compared to 50% of the skull base tumor group. Aspiration in patients with UVFI was associated with abnormally reduced pharyngeal constriction. Delayed airway closure was common in both aspirators and non-aspirators.

Immediate and partial neural dysfunction after thyroid and parathyroid surgery: Need for recognition, laryngeal exam, and early treatment

BACKGROUND

Laryngeal dysfunction after thyroid and parathyroid surgery requires early recognition and a standardized approach for patients that present with voice, swallowing, and breathing issues. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to define the terms "immediate vocal fold paralysis" and "partial neural dysfunction" and to provide clinical consensus statements based on review of the literature, integrated with expert opinion of the group.

METHODS

A multidisciplinary expert panel constructed the manuscript and recommendations for laryngeal dysfunction after thyroid and parathyroid surgery. A meta-analysis was performed using the literature and published guidelines. Consensus was achieved using polling and a modified Delphi approach.

RESULTS

Twenty-two panelists achieved consensus on five statements regarding the role of early identification and standardization of evaluation for patients with "immediate vocal fold paralysis" and "partial neural dysfunction" after thyroid and parathyroid surgery.

CONCLUSION

After endorsement by the AHNS Endocrine Section and Quality of Care Committee, it received final approval from the AHNS Council.

Prevalence, incidence, and characteristics of dysphagia in those with unilateral vocal fold paralysis

OBJECTIVES/HYPOTHESIS

The purpose of this study was to investigate the impact of dysphagia definition on the incidence and overall prevalence of dysphagia in patients with unilateral vocal fold paralysis (UVP) stratified by etiology.

STUDY DESIGN

Retrospective medical chart review.

METHODS

Data was collected from the records of individuals diagnosed with UVP from 2013 to 2018, including patient demographics, dysphagia questionnaire total scores, clinical evaluation dysphagia symptoms, and instrumental swallow assessment outcomes. The annual incidence and overall prevalence of dysphagia were calculated by etiology as counts and percentages across five operational definitions of dysphagia.

RESULTS

A total of 415 individuals met inclusion criteria for the study. Annual prevalence estimates ranged from 19% to 55%, depending on the definition of dysphagia used. The highest prevalence of dysphagia occurred when defined by symptoms or signs identified by the clinician (55%). The lowest prevalence of dysphagia occurred using a definition of abnormal swallowing function documented during instrumental assessment (19%). Dysphagia questionnaire scores were more frequently abnormal in those with iatrogenic than idiopathic etiology of UVP (adjusted P = 0.014). Rate of instrumental assessment and documentation of aspiration was highest for central UVP etiology (33%). On average, pneumonia was rare (6%) irrespective of UVP etiology.

CONCLUSION

Up to 55% of patients diagnosed with UVP complained of dysphagia, but only 21% had dysphagia symptoms severe enough to prompt instrumental assessment. Incidence and severity of dysphagia varied depending on UVP etiologic category as well as dysphagia definition. The etiology of UVP may impact dysphagia risk and severity in this population and warrants further investigation.

LEVEL OF EVIDENCE

IV Laryngoscope, 130:2397-2404, 2020.