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Reprinted by permission of Laryngoscope. 2010; 120(7):1376-1382.

The Laryngoscope V C 2010 The American Laryngological, Rhinological and Otological Society, Inc.

Laryngoscopy of Vocal Fold Paralysis: Evalu- ation of Consistency of Clinical Findings

David E. Rosow, MD; Lucian Sulica, MD

poor. Glottic insufficiency, vocal fold bowing, and sali- vary pooling demonstrated the most agreement among responding laryngologists. These findings sug- gest a need for a standardized descriptive scheme for laryngoscopic findings in VFP. Key Words: Vocal fold paralysis, vocal cord paralysis, laryngoscopy, reliability, agreement. Level of Evidence: 2b Laryngoscope, 120:1376–1382, 2010 INTRODUCTION Laryngoscopy is the mainstay investigation in the di- agnosis of vocal fold paralysis (VFP), and not infrequently the sole diagnostic evaluation on which direct treatment (as opposed to treatment of underlying cause) is based. For much of the history of laryngology, complex nosologi- cal schemes have been constructed around the laryngoscopic appearance of VFP. Semon’s law, for instance, held that differences in vocal fold position were the product of differential vulnerability of adductor and abductor fibers of the recurrent laryngeal nerve. 1 Wagner and Grossman maintained that the position of the para- lyzed vocal fold was indicative of the integrity of the superior laryngeal nerve. 2,3 Such constructs were aban- doned as increasing anatomical knowledge and careful physiological investigations invalidated their assump- tions. In the course of this progress, systematic analysis of the laryngoscopic appearance of VFP has apparently been abandoned too, as unrewarding in the face of the evident complexity of the neuropathology underlying VFP. Yet, it is clear to any clinician that VFP manifests itself laryngoscopically in many different ways. Terms like height and length mismatch, arytenoid prolapse, flaccidity, posterior gap, and others that plainly refer to physical characteristics of the appearance of the para- lyzed vocal fold make their appearance in the professional discourse with some frequency. Woodson, in a seminal study of the paralyzed vocal fold, described several such features: foreshortening, arytenoid displace- ment, decreased vocal process contact, bowing, and ventricular hyperfunction. 4 Recent literature has addressed vocal process height asymmetry. 5,6 Both the configuration and degree of glottic insufficiency related to VFP have been presented as important in the selec- tion of treatment techniques. 7,8

Objectives/Hypothesis: Laryngoscopy is the principal tool for the clinical assessment of vocal fold paralysis (VFP). Yet no consistent, unified vocabulary to describe laryngoscopic findings exists, compromis- ing the evaluation and comparison of cases, outcomes, and treatment. The goal of this investigation was to evaluate laryngoscopic findings in VFP for inter- and intra-rater consistency. Study Design: Prospective survey-based study. Methods: Half-minute excerpts from strobo- scopic exams of 22 patients with VFP were mailed to 22 fellowship-trained laryngologists. Each reviewer was sent exams in randomized order, with three ran- dom repeats included to determine intra-rater reli- ability. Twelve laryngoscopic criteria were assessed and recorded on preprinted sheets. Eleven criteria were binary in nature (yes/no); glottic insufficiency was rated on a four-point scale (none/mild/moderate/ severe). Raters were blinded to clinical history, each other’s ratings, and to their own previous ratings. Inter-rater agreement was calculated by Fleiss’ kappa. Results: Twenty reviewers (91%) replied. Intra- rater reliability by reviewer ranged from 66% to 100% and by laryngoscopic criterion from 77% to 100%. Of the laryngoscopic criteria used, glottic insufficiency ( j ¼ 0.55), vocal fold bowing ( j ¼ 0.49), and salivary pooling ( j ¼ 0.45) showed mod- erate agreement between reviewers. Arytenoid sta- bility ( j ¼ 0.1), arytenoid position ( j ¼ 0.12), and vocal fold height mismatch ( j ¼ 0.12) showed poor agreement. The remainder showed slight to fair agreement. Conclusions: Inter-rater agreement on com- monly used laryngoscopic criteria is generally fair to

From the Department of Otorhinolaryngology, Weill Cornell Medical College, New York, New York, U.S.A. Editor’s Note: This Manuscript was accepted for publication March 17, 2010. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Lucian Sulica, MD, Director, Laryngology/ Voice Disorders, Department of Otorhinolaryngology, Weill Cornell Medi- cal College, 1305 York Avenue, New York, NY 10021. E-mail: lus2005@ med.cornell.edu

DOI: 10.1002/lary.20945

Laryngoscope 120: July 2010

Rosow and Sulica: Laryngoscopy of Vocal Fold Paralysis

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