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agreement) to 0.55 (moderate agreement). Ratings for
arytenoid stability, arytenoid position, and height mis-
match generated the poorest values, whereas glottic
insufficiency, vocal fold bowing, and salivary pooling
resulted in the best (Fig. 3–Fig. 8].
DISCUSSION
Traditionally conceptualized as an all-or-none phe-
nomenon, VFP has been shown by ample clinical and
laboratory investigation to represent a continuum of
neurogenic dysfunction encompassing partial denerva-
tion, complete denervation, and variable degrees and
patterns of reinnervation. It should come as no surprise,
then, that its clinical appearance too is highly variable.
This is not synonymous with random, however; this vari-
ability no doubt reflects the considerable heterogeneity
in the neurologic dysfunction that underlies the immo-
bile vocal fold. Historical efforts to decipher the
laryngoscopic appearance have fallen short, compro-
mised by oversimplifications and an incomplete
understanding of the relevant pathophysiology. Given
these limitations, we find these failures neither particu-
larly surprising nor discouraging.
Lest a re-examination of laryngoscopy in VFP be
considered unnecessary or irrelevant, it is important to
appreciate that existing neurodiagnostic techniques have
also been defeated by the complex neurologic picture
underlying the paralyzed vocal fold. Electromyography
has proved to be as qualitative as laryngoscopy, and it is
similarly susceptible to individual variation in interpre-
tation. Although it has yielded crucial insight in the
Fig. 5. Vocal fold tone decreased. This case generated the most
consistent rating for decreased vocal fold tone. All ratings were
made from dynamic examinations. [Color figure can be viewed in
the online issue, which is available at .]
Fig. 6. Vocal fold shortened. This case generated the most con-
sistent rating for shortened vocal fold. All ratings were made from
dynamic examinations. [Color figure can be viewed in the online
issue, which is available at .]
Fig. 7. Glottic insufficiency: none to mild. This case generated the
most consistent rating for no or mild glottic insufficiency. All rat-
ings were made from dynamic examinations. [Color figure can be
viewed in the online issue, which is available at www.interscience.
.]
Fig. 8. Glottic insufficiency: moderate to severe. This case gener-
ated the most consistent rating for moderate to severe glottic
insufficiency. All ratings were made from dynamic examinations.
[Color figure can be viewed in the online issue, which is available
at .]
Laryngoscope 120: July 2010 Rosow and Sulica: Laryngoscopy of Vocal Fold Paralysis
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