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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
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.
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.eduDOI: 10.1002/lary.25004
Laryngoscope 125: April 2015
Wu and Sulica: Paresis Survey
Reprinted by permission of Laryngoscope. 2015; 125(4):904-908.
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