Abstract Laryngeal electromyography (LEMG) is a technique used to characterize neuropathic injuries to the recurrent laryngeal nerve (RLN) and superior laryngeal nerve (SLN). The RLN and SLN ...innervate the laryngeal muscles to produce vocal fold (VF) motion and elongation, respectively. VF motion deficiencies can affect voice, swallowing, and breathing, which can greatly affect a patient's quality of life. Neuropathy‐related VF motion deficiencies most often result from surgical interventions to the skull base, neck, or chest likely due to the circuitous route of the RLN. LEMG is ideally conducted by an electromyographer and an otolaryngologist using a team‐approach. LEMG is a powerful diagnostic tool to better characterize the extent of neuropathic injury and thus clarify the prognosis for VF motion recovery. This updated review discusses current techniques to improve the positive and negative predictive values of LEMG using laryngeal synkinesis and quantitative LEMG. Synkinesis can be diagnosed by comparing motor unit potential amplitude during vocalization and sniff maneuvers when recording within adductor muscles. Quantitative turns analysis can measure motor unit recruitment to avoid subjective descriptions of reduced depolarization during vocalization, and normal values are >400 turns/s. By integrating qualitative, quantitative, and synkinetic data, a robust prognosis can help clinicians determine if VF weakness will recover. Based on LEMG interpretation, patient‐centered treatment can be developed to include watchful waiting, temporary VF augmentation, or definitive medialization procedures and laryngeal reinnervation.
Objective
Posterior glottic stenosis (PGS) often requires a destructive surgical treatment. Early PGS treatment involves glottic dilation to reduce airway constriction associated with chronic PGS. ...Round laryngeal dilation may not optimize posterior glottic dilation due to the teardrop shape of the glottis and may injure vocal fold tissue. We compared pressure applied to the glottis during traditional single balloon dilation and a novel, anatomically appropriate dilation technique (teardrop‐shaped glottic dilation TSGD).
Methods
Pressure sensors were affixed at various points on a three‐dimensional printed glottic model. The anterior glottis was stented with a triangular stent (18‐32F) in combination with balloon dilator (10–20 mm) placed in the posterior glottis (TSGD) in 30 unique combinations. Force applied to the vocal folds (VF) and posterior commissure (PC) during round balloon dilation and TSGD was measured.
Results
Dilatory force in the PC ranged from 0.0–3.8 newtons (N) using balloon dilators and 0.0–17.5 N using TSGD. The TSGD technique yielded a superior ratio of force applied to the PC versus VF (P = 0.0296) compared to round balloon dilation alone. Optimal targeting of the PC occurred when the sum of the anteroposterior (AP) dimensions of the stent and balloon dilator approached the AP length of the glottis.
Conclusion
Use of an anatomically appropriate glottic dilation maximizes expansive force applied to the posterior commissure and decreased force to the vocal folds. This study demonstrates that TSGD minimizes force to the anterior glottis and maximizes dilation of the posterior glottis. This technique may play a role in preventing laryngeal stenosis associated with chronic PGS.
Level of Evidence
NA
Laryngoscope, 129:2239–2243, 2019
Objectives/Hypothesis
The Voice Handicap Index‐10 (VHI‐10) is commonly used to measure patients' perception of vocal handicap. Clinical consensus has previously defined clinically meaningful ...improvement as a decrease ≥5. This study determines the minimal clinically important difference (MCID) for VHI‐10 in patients with unilateral vocal fold paralysis (UVFP) using anchor‐based methodology.
Study Design
Prospective cohort questionnaire analysis.
Methods
Two hundred eighty‐one UVFP patients completed the VHI‐10 on two consecutive visits (within 3 months). At the follow‐up visit, patients answered an 11‐point Global Rating of Change Questionnaire (GRCQ) scored from −5 to +5. Relationship between the GRCQ and change in VHI‐10 was quantified using analysis of variance, and MCID for the VHI‐10 was determined using receiver operating characteristic (ROC) curve analysis.
Results
Overall mean VHI‐10 change was −3.71 (standard deviation SD = 8.89) and mean GRCQ was 1.37 (SD = 2.51). Average interval between measurements was 1.73 months (SD = 0.83). Mean changes in VHI‐10 scores were −7.45, −0.53, and +4.40 for patients whose GRCQ scores indicated improvement, no change, and worsening, respectively. Differences between mean scores were statistically significant (P < .001). Area under the ROC curve was 0.80, demonstrating the classification accuracy of VHI‐10 change scores. A VHI‐10 change of −4 was determined to be the optimal threshold that discriminated between improvement and no improvement (sensitivity and specificity 0.62 and 0.88, respectively).
Conclusions
The MCID for improvement in VHI‐10 in UVFP patients is a decrease of 4. This information improves understanding of patients' response to treatment and allows comparison between different treatments. Future research should determine MCID for VHI‐10 across all voice disorders.
Level of Evidence
4. Laryngoscope, 128:1419–1424, 2018
Recurrent Respiratory Papillomatosis (RRP) is a rare disease characterized by the growth of papillomas in the airway and especially the larynx. The clinical course is highly variable among ...individuals and there is poor understanding of the factors that drive an aggressive vs an indolent course.
A convenience cohort of 339 affected subjects with papillomas positive for only HPV6 or HPV11 and clinical course data available for 1 year or more, from a large multicenter international study were included. Exploratory data analysis was conducted followed by inferential analyses with frequentist and Bayesian statistics.
We examined 339 subjects: 82% were diagnosed prior to the age of 18 years, 65% were infected with HPV6, and 69% had an aggressive clinical course. When comparing age at diagnosis with clinical course, the probability of aggressiveness is high for children under five years of age then drops rapidly. For patients diagnosed after the age of 10 years, an indolent course is more common. After accounting for confounding between HPV11 and young age, HPV type was minimally associated with aggressiveness. Fast and Frugal Trees (FFTs) were utilized to determine which algorithms yield the highest accuracy to classify patients as having an indolent or aggressive clinical course and consistently created a branch for diagnostic age at ~5 years old. There was no reliable strong association between clinical course and socioeconomic or parental factors.
In the largest cohort of its type, we have identified a critical age at diagnosis which demarcates a more aggressive from less aggressive clinical course.
Objectives/Hypothesis
To create a model of the anatomic distribution, recurrence, and growth patterns of recurrent respiratory papillomatosis (RRP).
Study Design
Prospective, multi‐institutional ...cohort study.
Methods
Adult patients with a diagnosis of RRP evaluated between August 1, 2018 and February 1, 2021 at six participating centers were invited to enroll. At each office or operating room encounter, laryngologists recorded the location and size of RRP lesions using a 22‐region schematic. A generalized linear mixed effects model was used to compare region variations in lesion prevalence and recurrence.
Results
The cohort comprised 121 patients: 74% were male, 81% had been diagnosed with adult‐onset RRP, and a plurality (34%) had undergone 0 to 3 RRP interventions prior to enrollment. Across the study period, the odds of a lesion occurring in the glottis was significantly higher (odds ratio OR: 26.51; 95% confidence interval CI: 11.76–59.75, P < .001) compared with all other areas of the larynx and trachea. Within the true vocal folds, the membranous vocal folds had significantly higher odds (OR: 6.16; 95% CI: 2.66–14.30, P < .001) of lesion occurrence compared to the cartilaginous vocal folds. Despite these strong trends in lesion distribution, there were no differences in the odds of lesion recurrence, growth, or in the time to recurrence, between anatomic subsites.
Conclusions
RRP lesions are most likely to occur in the glottis, particularly the membranous vocal folds, compared with other regions of the larynx or trachea. However, all lesions demonstrate similar behavior with respect to recurrence, growth, and time to recurrence regardless of anatomic location.
Level of Evidence
3 Laryngoscope, 132:2403–2411, 2022
The potential for negative sequalae in psychosocial well-being presents clinical importance to the assessment of voice disorders. Despite the impairment voice disorders cause in the psychosocial ...domain, the clinical assessment of these disorders relies heavily on visual perceptual judgments of the larynx, audio-perceptual, as well as acoustic and aerodynamic measures. While these measures aid in accurate diagnosis and are necessary for standard of care, they present little insight into the patient experience of having a voice disorder.
Retrospective between-subject, non-experimental design.
Data from 335 patients from the University of Pittsburgh Voice Center were collected from scores of the Voice Handicap Index-10 (VHI-10) and two recent questionnaires, the Voice Present Perceived Control scale (VPPC), and the Vocal Congruency Scale (VCS). Examining how these voice-specific scales related to three mental health screeners for stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7) and depression (Patient Health Questionnaire-9) were also examined. Patient diagnoses included primary muscle tension dysphonia (pMTD), unilateral vocal fold paralysis (UVFP), vocal fold atrophy, and mid membranous vocal fold lesions.
There were significant differences in scores from the voice-specific scales between diagnostic groups with UVFP being the highest (worst) in VHI-10 and UVFP being the lowest (worst) in VCS compared to healthy controls. There was no significant difference in VPPC scores between diagnostic groups. Results showed statistically significant inverse relationships between the VHI-10 and the VPPC and between the VHI-10 and VCS for all diagnostic groups. A significant direct relationship was found between the VPPC and the VCS for patients diagnosed with MTD, UVFP and Lesions. In sum, patients with UVFP presented with the most frequent and sometimes strongest relationships between voice and mental health measures.
This study marks an initial investigation into the nuanced patient experience of having a voice disorder. Three theoretically unrelated voice constructs: handicap, perceived control, and sense of self, were measured via self-report. Results from this study describe the patient experience correlating to these constructs with weak correlations to stress, anxiety, and depression. Findings also clearly suggest that patient experience varies among diagnostic groups, as well as varying constructs. Measures of multiple constructs of patient perception provide valuable insight into a patient's experience of their voice disorder, guidance on the direction of voice treatment, and justification for such treatments.
Objective:
Cricoid chondronecrosis is a rare entity that has significant consequences for patients. Reports of its occurrence are scattered in the literature and currently there is no comprehensive ...review to help guide providers.
Methods:
A case report from our institution is presented. A review of available literature is then provided with assessment of risk factors, signs and symptoms at presentation, laryngeal exam findings, radiologic findings, and surgical techniques.
Results:
Twenty-four cases of cricoid chondronecrosis were reviewed from the literature. Patient age ranged from 8 months to 76 years. A history of endotracheal intubation for various reasons was present in all but two cases, and duration of intubation ranged from 6 hours to 28 days. Patients presented with airway compromise in all but two cases—one asymptomatic patient with prior tracheostomy and another with dysphagia after radiation. Dysphonia (n = 6) and dysphagia (n = 3) were less commonly present. Subglottic stenosis (n = 19) was the most common exam finding followed by vocal fold impairment (n = 11). When CT scan findings were reported, fragmentation of the cartilage and/or hypodensity of the central lamina were described in all but one case. Interventions ranged from observation on antibiotics and steroids to surgical therapies including tracheostomy, dilation, and posterior cricoid split, with or without stent placement.
Conclusions:
Cricoid chondronecrosis is a serious, rare entity that can occur even after a short period of endotracheal intubation. Providers must have a high level of suspicion in patients that present with upper airway dyspnea with a history of prior intubation.
Level of evidence:
Level 4
Technical Challenges for Laryngeal Electromyography Lin, R. Jun; Munin, Michael C.; Belsky, Michael ...
The Laryngoscope,
February 2024, 2024-Feb, 2024-02-00, 20240201, Volume:
134, Issue:
2
Journal Article
Peer reviewed
Background/Objective
Laryngeal electromyography (LEMG) is a useful diagnostic test in the evaluation of vocal fold paralysis (VFP). This study investigates factors that can make LEMG challenging to ...perform.
Methods
Patients with subacute unilateral VFP presented for LEMG were prospectively enrolled. Demographic data including BMI, previous neck surgery, and anatomic factors were collected. Patient‐reported pain related to the procedure was recorded on a visual analogue scale (VAS). Electromyographer and otolaryngologist recorded a consensus rating of the perceived difficulty in performing the test and confidence in using the results for clinical decision‐making.
Results
A total of 111 patients (56.8% female) were enrolled between August 2015 and August 2018. The mean age was 55 ± 14 years, and the average body mass index (BMI) was 28.5 ± 6.4. The mean patient‐reported VAS score for pain was 35 ± 24. Notably, 31.2% of the tests were considered “very easy,” 32.1% were considered “mildly challenging” and 23.9% and 12.8% were considered “moderately challenging” and “extremely challenging,” respectively, by the clinicians. Common factors affecting LEMG difficulty included poorly palpable surface anatomy (50.5%) and patient intolerance (15.6%). Clinicians felt confident in 76.1% of the test findings. Bivariate analyses showed that prior neck surgery is associated with elevated VAS (p = 0.02), but clinician‐perceived difficulty of performing the test is not associated with elevated VAS scores (p = 0.55).
Conclusions
Majority of LEMG tests are well tolerated by patients. Physicians reported more confidence using LEMG for clinical decision‐making when the test was easier to perform. Difficult surface anatomy and patient intolerance affects clinician confidence in integrating the test results with clinical care.
Level of Evidence
3 Laryngoscope, 134:831–834, 2024
Objectives
Posterior glottic stenosis (PGS) results in severe derangement of laryngeal configuration and function with significant morbidity as a sequalae. Presently, there is no treatment for ...patients with “early” PGS. Dilation is often used for stenotic disease, but present dilation methods are limited to a round shape and the glottis is a sector (teardrop‐shaped). Round dilation of the larynx results in compression of the membranous vocal folds (with potential for injury) and minimal expansion of the posterior larynx. We present a novel laryngeal dilation method that matches the unique anatomic shape of the glottis: teardrop‐shaped glottis dilation (TSGD).
Methods
We present a clinical series of early PGS patients treated with a TSGD. Five patients with dyspnea and significantly reduced vocal fold mobility due to early PGS were treated with TSGD, which involves placement of a triangular static stent in the anterior glottis, with simultaneous use of a round balloon dilator in the posterior glottis.
Results
All patients reported improved ease of breathing and decrease in Dyspnea Index score and were decannualated following treatment. Video perceptual analysis of pre‐/postlaryngoscopy examinations was performed with five blinded reviewers, and all patients were scored to have improved posterior glottic airway space following treatment with a mean improvement of 2.4 on a 11‐point scale.
Conclusion
These clinical results demonstrate that there is enormous potential for the identification and treatment of patients with early PGS and use of a laryngeal dilation technique that matches the anatomic configuration of the glottis.
Level of Evidence
4
Laryngoscope, 129:1428–1432, 2019
Objective
Treatment options for symptomatic unilateral vocal fold paralysis (VFP) include vocal fold augmentation, laryngeal framework surgery, and laryngeal reinnervation. Laryngeal reinnervation ...(LR) has been suggested to provide “tone” to the paralyzed VF. This implies a loss of tone as a result of denervation without reinnervation. We performed laryngeal electromyography (LEMG) in patients with chronic VFP to understand the innervation status associated with a chronically paralyzed vocal fold.
Study Design
Retrospective review of LEMG data in adult patients with chronic VFP from January 2009 to December 2014.
Methods
LEMG was performed at least 6 months after‐onset of VFP. Qualitative LEMG, quantitative LEMG, and adductory synkinesis testing were performed, and the parameters were collected.
Results
Twenty‐seven vocal folds were studied (23 unilateral VFP and 2 bilateral VFP). Average age was 59 ± 17 years. The median duration from recurrent laryngeal nerve injury to LEMG was 8.5 months (range 6–90 months). The majority of patients, 24 of 27 (89%), had motor unit potentials during phonation tasks on LEMG, and only 3 of 27 (11%) patients were electrically silent. Quantitative LEMG showed 287.8 mean turns per second (normal ≥ 400). Motor unit configuration was normal in 12 of 27 (44%), polyphasic in 12 of 27 (44%), and absent in the electrically silent patients. Adductory synkinesis was found in 6 of 20 (30%) patients.
Conclusion
Chronic vocal fold paralysis is infrequently associated with absent motor‐unit recruitment, indicating some degree of preserved innervation and/or reinnervation in these patients. LEMG should be part of the routine workup for chronic VFP prior to consideration of LR.
Level of Evidence
4. Laryngoscope, 128:1628–1633, 2018
PDF
