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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
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
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
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.eduDOI: 10.1002/lary.20945
Laryngoscope 120: July 2010
Rosow and Sulica: Laryngoscopy of Vocal Fold Paralysis
Reprinted by permission of Laryngoscope. 2010; 120(7):1376-1382.
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