HSC Section 6 Nov2016 Green Book

Fig. 3. A 30-year-old woman with a left-sided contact lesion and decreased left vocal fold adduction.

Fig. 1. A 44-year-old man with atrophy of the left hemilarynx, man- ifested as an enlarged laryngeal ventricle, and the beginning of a right vocal fold pseudocyst.

eral, abnormalities of gross vocal fold motion were con- sidered to be most highly predictive, followed by stroboscopic signs. Associated lesions, namely contact lesions and pseudocysts, were not considered highly diagnostic of paresis. Respondents rated the sensitivity of LEMG at 61 6 3.7%, r 5 28. DISCUSSION The prevalence and clinical importance of VFP is not yet established, which should not be surprising when diagnostic criteria remain under discussion, but it has the potential to be substantial. Among our respond- ents, VFP was diagnosed 8 times in a typical month, or roughly 100 times per year, and was found in about one- sixth of new patients presenting with voice complaints. By comparison, the largest reported series of VFP only consist of under 50 patients per year reviewed. 2,3,5 The prevalence of paresis has been proposed to be similar to paralysis on the basis of similar pathophysiology. 1 The prevalence of paralysis varies widely from report to report and is dependent on practice environment, geo- graphic location, patient selection, and a host of other factors. Studies from one center have reported 46% prev- alence of mild vocal hypomobility among patients with vocal complaints, 15% to 23% among singing teachers without vocal complaints, and 71% among singing teach- ers with technical difficulty complaints. 12–14 Simpson et al. 5 drew cases from a series of 739 patients present- ing to their tertiary laryngology practice over a 4-year period with a chief complaint of dysphonia. Of 195 (26.4%) patients initially diagnosed with VFP or paraly- sis by videostroboscopy, only 13 or 1.8% of the overall dysphonic patients had LEMG-confirmed unilateral or bilateral VFP. Koufman et al. 15 reviewed 415 patients who underwent LEMG over a 5-year period. This group found “abnormal diagnostic LEMG” results (presumed to TABLE I. Respondent Demographics (N 5 58). Years in practice posttraining 11 6 1.1 ( r 5 8.6, range 0.1–31) Laryngology fellowship trained 54 (93%) Practicing in the United States 56 (97%) Percent of practice which is laryngology 93 6 1.0% Percent adult patients 91 6 1.1%

This questionnaire was distributed to attendees at three national laryngology conferences that took place in 2013: 1) the Neurolaryngology Study Group at the American Academy of Otolaryngology Annual Meeting, Vancouver, BC; 2) the Fall Voice Conference, Atlanta, GA; and 3) Advances and Controver- sies in Laryngology, Elk Grove, IL. Duplicate responses were avoided, and confidentiality was preserved by separately track- ing responder identity. Responses were collated anonymously and subjected to cross-tabulated data analysis. Only otolaryng- ologists were surveyed. Physicians whose practices did not predominantly focus on laryngology ( < 75% laryngology), who did not see patients with dysphonia as a chief complaint, or who never diagnosed patients with VFP were excluded. Responders still in training, whether in residency or fellowship, were also excluded. Incom- plete surveys were removed from analysis. One response with internally conflicting responses (a greater number of monthly paresis diagnoses than new dysphonic patients) was excluded. Statistical analysis using descriptive frequencies and cross- tabulations were performed with 2011 Microsoft Excel. RESULTS A total of 88 responses were received. After apply- ing the exclusion criteria, a total of 58 entries were included for data analysis. Respondent demographics are summarized in Table I. The vast majority of respondents are laryngology fellowship-trained otolar- yngologists with predominantly adult practices in the United States. Practice specifics related to VFP are sum- marized in Table II. Most respondents (72%) base diag- nosis principally on stroboscopy. Only 12 (21%) respondents performed LEMG on greater than 50% of their VFP patients. Figure 4 and Table III summarize the respondents’ opinion regarding positive predictive value of laryngoscopic findings in VFP patients. In gen-

Fig. 2. A 38-year-old woman with atrophy of the left vocal fold, incomplete glottic closure, unilateral (right) supraglottic hyperfunction, and impairment of arytenoid rotation on the left.

Laryngoscope 125: April 2015

Wu and Sulica: Paresis Survey

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