HSC Section 6 Nov2016 Green Book

Reprinted by permission of Laryngoscope. 2015; 125(4):904-908.

The Laryngoscope V C 2014 The American Laryngological, Rhinological and Otological Society, Inc.

Diagnosis of Vocal Fold Paresis: Current Opinion and Practice

Amy P. Wu, MD; Lucian Sulica, MD

Objectives/Hypothesis: No accepted standard exists for the diagnosis of vocal fold paresis (VFP). Laryngeal specialists are surveyed to establish expert opinion on diagnostic methodology and criteria. Study Design: Cross-sectional survey. Methods: Questionnaires were distributed at laryngology conferences in fall 2013. Responses were collated anony- mously and subjected to cross-tabulated data analysis. Results: Fifty-eight responses completed by posttraining physicians whose practice focused in laryngology 75% were analyzed. One (1.7%) relied principally on laryngeal electromyography, one (1.7%) on history, 10 (17%) on laryngoscopy, and 42 (72%) on strobovideolaryngoscopy for diagnosis. Only 12 (21%) performed laryngeal electromyography on > 50% of vocal fold paresis patients. Laryngeal electromyography sensitivity was considered moderate (61 6 3.7%, r 5 28). Laryngoscopic/ stroboscopic findings considered to have the strongest positive predictive value for VFP were slow/sluggish vocal fold motion (75 6 3.0%, r 5 23), decreased adduction (67 6 3.5%, r 5 27), decreased abduction (65 6 3.4%, r 5 26), and decreased vocal fold tone (61 6 3.5%, r 5 26). Asymmetric mucosal wave amplitude (52 6 4.2%, r 5 32), asymmetric mucosal wave phase (60 6 4.1%, r 5 31), hemilaryngeal atrophy (60 6 4.0%, r 5 31), and asymmetric mucosal wave frequency (49 6 4.0%, r 5 30) generated greatest disagreement. Conclusions: Surveyed expert laryngologists diagnose vocal fold paresis predominantly on stroboscopic examination. Gross motion abnormalities had the highest positive predictive value. Laryngeal electromyography was infrequently used to assess for vocal fold paresis. Key Words: Vocal fold paresis, laryngeal electromyography, laryngoscopy, stroboscopy. Level of Evidence: 5 Laryngoscope , 125:904–908, 2015

INTRODUCTION Vocal fold paresis (VFP) is a partial motor denerva- tion of the vocal fold causing variable degrees of compro- mised glottal function. 1 Appreciation of its clinical significance has grown hand in hand with an increas- ingly sophisticated understanding of laryngeal neuropa- thy, and it continues to evolve. Although not different in kind but only in degree from vocal fold paralysis, VFP is often considered separately; the spectrum of difficulties it causes is different, and perhaps most important, its diagnosis is more challenging and controversial. Paresis is usually diagnosed based on qualitative findings on lar- yngoscopy, stroboscopy, and/or laryngeal electromyogra- phy (LEMG). Endoscopic diagnosis typically rests on the Additional Supporting Information may be found in the online version of this article. From the New York Center for Voice and Swallowing Disorders, Department of Otolaryngology–Head and Neck Surgery, St Luke’s–Roo- sevelt Hospital ( A . P . W .); and the Sean Parker Institute for the Voice, Department of Otolaryngology–Head and Neck Surgery, Weill Cornell Medical College ( L . S .), New York, New York, U.S.A. Editor’s Note: This Manuscript was accepted for publication October 7, 2014. Scheduled to be presented at the 136th Annual Meeting of the American Laryngological Association, Las Vegas, NV, U.S.A., May 14–15, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Lucian Sulica, MD, 1305 York Avenue, 5th Floor, New York, NY 10021. E-mail: lus2005@med.cornell.edu

observation of asymmetries of laryngeal motion. How- ever, some asymmetry in laryngeal motion may be with- out clinical significance. Electromyographic findings may be indistinct as well. 1–4 In the absence of a standard for diagnosis, investigation of important aspects of paresis including causes, incidence, natural history, and effec- tiveness of treatment is challenging. In the context of these limitations, expert clinical consensus may provide a useful basis to initiate discourse regarding VFP. The purpose of this investigation is to describe expert opinion regarding the diagnosis of VFP by means of a survey of practicing laryngeal specialists. MATERIALS AND METHODS A 29-item, 4-part questionnaire (see Appendix 1) was designed to characterize responders’ experience, training and practice setting (part 1), assess diagnostic strategy (part 2), evaluate opinion regarding the positive predictive value of vari- ous laryngoscopic signs (part 3), and evaluate option regarding the sensitivity of LEMG (part 4). The roster of laryngoscopic signs was compiled from clinical experience, consultation with colleagues, and a review of the literature regarding VFP diagno- sis and VFP-associated lesions. It included vocal fold hypomobil- ity, 1,2,5 glottic insufficiency, 1,5 unilateral atrophy, 1 supraglottic hyperfunction, 2,6 mucosal wave asymmetries, 5,7 glottic axis deviation, 2,5 vocal fold height mismatch, arytenoid rotation, 8 and presence of a contact lesion 2,9,10 or pseudocyst. 2,11 Examples are illustrated in Figures 1 to 3. Opinion regarding each sign and LEMG sensitivity was assessed using a visual analog scale.

DOI: 10.1002/lary.25004

Laryngoscope 125: April 2015

Wu and Sulica: Paresis Survey

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