- Email: [email protected]
Point of care, clinician-performed laryngeal ultrasound and pediatric vocal fold movement impairment
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109773
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Point of care, clinician-performed laryngeal ultrasound and pediatric vocal fold movement impairment
T
Wynne Q. Zhanga, Elton M. Lambertb,c, Julina Ongkasuwanb,c,∗ a
Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA Texas Children's Hospital, Pediatric Otolaryngology, 6701 Fannin, Mark Wallace Tower, Suite 540, Houston, TX, 77030, USA c Baylor College of Medicine, Department of Otolaryngology Head and Neck Surgery, 1977 Butler St., 5th floor, Houston, TX, 77030, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Laryngeal ultrasound Vocal fold motion impairment Vocal fold paralysis Pediatric Vocal cord paralysis
Introduction: Vocal fold movement impairment (VFMI) is a well-known sequela of cervical and thoracic procedures performed in the vicinity of the recurrent laryngeal nerve. Interpretation of flexible nasolaryngoscopy (FNL) can be difficult in young children due to crying, secretions, and obstructing supraglottic structures. We have previously published on the use of radiologist performed and interpreted, laryngeal ultrasound (LUS) to evaluate vocal fold mobility with substantial agreement with FNL in infants in the cardiovascular intensive care unit. The purpose of this study was to evaluate point of care, clinician performed, LUS for vocal fold mobility in a pediatric voice clinic. Methods: LUS and FNL were performed and recorded on 30 consecutive patients (11 with a clinical diagnosis of VFMI and 19 with clinically normal mobility) in a pediatric voice clinic. All LUS was performed by a single clinician (reviewer 1) with a GE logiq P9 and 12 MHz linear probe. Deidentified recordings of the LUS and FNL (without sound) were reviewed in random order by 2 fellowship trained pediatric otolaryngologists who were blinded to the vocal fold mobility. Cohen's kappa was used to determine agreement. Results: There was substantial agreement (κ = 0.7) between the reviewers regarding interpretation of LUS as well as regarding interpretation of FNL κ = 0.7802. In addition, each reviewer had near perfect to substantial agreement between their interpretation of the LUS and FNL (reviewer 1 κ = 0.9294 and reviewer 2 κ = 0.8413). Conclusion: Point of care, clinician performed, LUS can be used for the identification of VFMI with substantial agreement with FNL with good inter-rater reliability. This provides clinicians with another tool in their armamentarium for the evaluation of challenging larynges.
1. Introduction Vocal fold movement impairment (VFMI) is a known sequela of cervical and thoracic surgeries due to the long circuitous route of the recurrent laryngeal nerve,. The reported incidence of VFMI following pediatric cardiac surgery varies from 1.1% to 67% [1–8], depending on the patient population and whether screening was performed on all patients postoperative patients versus r symptomatic ones. A pooled estimate of 33 studies suggests an incidence of 7.9% following surgical closure of patent ductus arteriosus [9]. In a systematic review of studies that excluded isolated patent ductus arteriosus closure to focus open cardiac surgery, rates of VFMI diagnosis ranged from 8 to 59% [10]. Unilateral VFMI can result in dysphagia and/or a weak and breathy voice, and stridor in some infants. Currently the standard for diagnosis of VFMI is flexible ∗
nasolaryngoscopy (FNL). However, in children, FNL can be challenging and inexact due to cooperation, secretions, and obstructing supraglottic structures. In addition, FNL can cause significant physiologic changes in blood pressure, heart rate and oxygen saturation, which can be a particular concern in vulnerable groups such as congenital heart disease and pulmonary hypertension [11,12]. It has also been shown that without sound to aid diagnosis, there was only moderate interrater reliability for identification of the degree of vocal fold movement in infants (k = 0.49) [13]. Transcervical laryngeal ultrasound (LUS) is an alternate way of assessing vocal fold mobility, which causes fewer changes in physiologic parameters. LUS was first described by Garel et al., in 1990. In 1997, Friedman published its use for identification of VFMI in children with agreement between the two modalities in 87–94% of cases with a minimum weighted k value of 0.75. Since then, other groups have
Corresponding author. Texas Children's Hospital, Pediatric Otolaryngology, 6701 Fannin, Mark Wallace Tower, Suite 540, Houston, TX, 77030, USA. E-mail addresses: [email protected] (W.Q. Zhang), [email protected] (E.M. Lambert), [email protected] (J. Ongkasuwan).
https://doi.org/10.1016/j.ijporl.2019.109773 Received 16 August 2019; Received in revised form 29 October 2019; Accepted 4 November 2019 Available online 09 November 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109773
W.Q. Zhang, et al.
Fig. 1. Laryngeal ultrasound.
digital flexible rhinolaryngoscope (Karl Storz Tuttlingen, Germany) in older children. Deidentified recordings of the LUS and FNL (without sound) were reviewed in random order by two fellowship trained pediatric otolaryngologists who were blinded to the vocal fold mobility. Qualitative mobility was reported as normal vs. VFMI (Fig. 1). For each reviewer, Cohen's kappa was used to determine agreement between interpretation of LUS and FNL. Cohen's kappa was also used to evaluate inter-rater agreement in interpretation of LUS.
explored the use of radiologist-performed LUS in assessment of vocal fold mobility. In 2004, Vats et al. found LUS to be in concordance with FNL 81.2% of the time in their sample of 55 patients ages three days to 12 years. In 2011, Wang et al. [14] further described identifying VFMI on LUS through criteria including abnormal mobility, asymmetry of structures, and flaccidity of the vocal fold, and reported high agreement (k = 0.96) between findings on FNL and LUS. In 2017, we published our experience at Texas Children's Hospital with radiologist-performed and interpreted laryngeal ultrasound (LUS) compared to FNL in patients in the pediatric cardiovascular intensive care unit [12]. We used measurements of the arytenoid-vocal fold angle in adduction and abduction. In 2018, Lee et al. reported that LUS had a 95% sensitivity and 88% specificity compared to FNL in identifying VFMI in a population of 52 pediatric patients following aortic arch repair [15]. While these prior studies have relied on radiologists or trained imaging specialists, increasingly portable and affordable ultrasound technology has led the drive to explore further applications of LUS as a point of care, clinician-performed exam. In recent years, the use of perioperative surgeon-performed LUS evaluation of vocal fold mobility has been explored in the adult population [16], and in 2015, Wong et al. showed that surgical residents trained to identify VFMI via LUS in adult patients could be considered competent following 7 ultrasound examinations and experienced after 40 [17]. Our goal in this study was to evaluate the use of LUS as a point of care, otolaryngologist-performed assessment of vocal fold movement in the pediatric population.
3. Results Thirteen of the patients were female and 17 were male. Ages ranged from 3 months to 17 years with a median age of 4 years and 6 months. Reasons for referral and clinical vocal fold mobility findings are listed in Table 1. Interrater agreement regarding interpretation of LUS was κ = 0.7 and for interpretation of FNL was κ = 0.7802. In addition, each reviewer had near perfect to substantial agreement between their own interpretation of the LUS and FNL (reviewer 1 κ = 0.9294 and reviewer 2 κ = 0.8413). Raw data is shown in Table 1 with non-congruent results highlighted in grey. 4. Discussion In this study we aimed to show that qualitative interpretation of LUS can be used by clinicians to evaluate vocal fold mobility. Our previous work used quantitative measurements of vocal fold – arytenoid angles to determine mobility. However, often clinicians do not have the time or inclination to perform these measurements. Qualitative interpretation of LUS is, in fact, similar to the way in which most otolaryngologists are accustomed to interpreting FNL. As we observed in our previous study, the vocal fold edge and thus glottic closure is difficult to assess with LUS. Because of its density, arytenoid rotation is the easiest structure to appreciate. Our results are comparable to those of previous studies that used radiologists, with reported kappa values for comparison of LUS to FNL ranging from 0.75 to 0.96 [14,15,18]. This suggests that the transition of LUS to a clinician-performed exam at bedside or in clinic will not sacrifice the accuracy of the test. It should be noted that there were instances in which the reviewers' interpretations of the FNL recordings were not congruent with each other (in a blinded context) or with the initial, in clinic, FNL and
2. Material and methods With Institutional Review Board Approval, LUS and FNL were performed and recorded on 30 consecutive patients (11 with a clinical diagnosis of VFMI and 19 with clinically normal mobility at the time of FNL and LUS) in a pediatric voice clinic. Diagnosis of VFMI and resultant categorization for the study was determined by the clinical, in office, impression based on FNL findings. All LUS was performed by a single clinician (reviewer 1) on the same day as the FNL with a GE logiq P9 ultrasound and 12 MHZ linear probe (GE Healthcare, Boston, MA). The patients were positioned typically in a parent's lap with the neck in extension. Ultrasound was performed with probe placed over the cricothyroid membrane angled slightly superiorly. The probe was orientated such that the right vocal fold was on the left side of the screen. FNL was performed with an Olympus ENF-XP 2.2 mm flexible fiber laryngoscope in infants (Olympus Tokyo, Japan) and Karl Storz 3.7 mm 2
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109773
W.Q. Zhang, et al.
Table 1 Patient demographics and reviewer Data.
provides additional information that may aid in diagnosis of VFMI in patients who cannot undergo FNL.
examination. The imperfect agreement between the reviewers regarding the recorded FNL's is consistent with our previously published data [13]. This is a relatively small study performed at a single institution, largely by a single clinician, reviewer 1, thus limiting its generalizability. However, because LUS interpretation is relatively intuitive to clinicians accustomed to viewing FNL, reviewer 2 was able interpret the LUS without any direct instruction. In additional, LUS cannot assess supraglottic or subglottic structures as part of the evaluation of stridor.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest 5. Conclusions The authors have no financial interest or conflicts of interest to disclose.
The portability, ease of use, lack of radiation, low cost and dynamic imaging capabilities of LUS make it a useful addition to the clinical repertoire of the otolaryngologist. LUS is well tolerated by patients and 3
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109773
W.Q. Zhang, et al.
References
116–125, https://doi.org/10.1007/s00246-018-1967-8. [10] S. Orzell, R. Joseph, J. Ongkasuwan, J. Bedwell, J. Shin, N. Raol, Outcomes of Vocal Fold Motion Impairment and Dysphagia after Pediatric Cardiothoracic Surgery: A Systematic Review, (2019), https://doi.org/10.1177/0194599819858594. [11] J. Ongkasuwan, K.C. Yung, M.S. Courey, The physiologic impact of transnasal flexible endoscopy, The Laryngoscope 122 (2012) 1331–1334, https://doi.org/10. 1002/lary.23358. [12] J. Ongkasuwan, E. Ocampo, B. Tran, Laryngeal ultrasound and vocal fold movement in the pediatric cardiovascular intensive care unit, The Laryngoscope 127 (2017) 167–172, https://doi.org/10.1002/lary.26051. [13] Y.C.C. Liu, T. McElwee, M. Musso, T.L. Rosenberg, J. Ongkasuwan, The reliability of flexible nasolaryngoscopy in the identification of vocal fold movement impairment in young infants, Int. J. Pediatr. Otorhinolaryngol. 100 (2017) 157–159, https:// doi.org/10.1016/j.ijporl.2017.07.005. [14] L.M. Wang, Q. Zhu, T. Ma, J.P. Li, R. Hu, X.Y. Rong, W. Xu, Z.C. Wang, Value of ultrasonography in diagnosis of pediatric vocal fold paralysis, Int. J. Pediatr. Otorhinolaryngol. 75 (2011) 1186–1190, https://doi.org/10.1016/j.ijporl.2011.06. 017. [15] M.G.Y. Lee, J. Millar, E. Rose, A. Jones, D. Wood, T.L. Luitingh, D. Zannino, J. Brink, I.E. Konstantinov, C.P. Brizard, Y. d'Udekem, Laryngeal ultrasound detects a high incidence of vocal cord paresis after aortic arch repair in neonates and young children, J. Thorac. Cardiovasc. Surg. 155 (2018) 2579–2587, https://doi.org/10. 1016/j.jtcvs.2017.12.133. [16] K.P. Wong, B.H.H. Lang, S.H. Ng, C.Y. Cheung, C.T.Y. Chan, C.Y. Lo, A prospective, assessor-blind evaluation of surgeon-performed transcutaneous laryngeal ultrasonography in vocal cord examination before and after thyroidectomy, Surgery (St Louis) 154 (2013) 1158–1165, https://doi.org/10.1016/j.surg.2013.04.063. [17] K.P. Wong, B.H.H. Lang, S. Lam, K.P. Au, D.T.Y. Chan, N.C. Kotewall, Determining the learning curve of transcutaneous laryngeal ultrasound in vocal cord assessment by CUSUM analysis of eight surgical residents: when to abandon laryngoscopy, World J. Surg. 40 (2016) 659–664, https://doi.org/10.1007/s00268-015-3348-2. [18] E.M. Friedman, Role of ultrasound in the assessment of vocal cord function in infants and children, Ann. Otol. Rhinol. Laryngol. 106 (1997) 199–209 http://www. embase.com/search/results?subaction=viewrecord&from=export&id= L27123210.
[1] K. Dewan, C. Cephus, V. Owczarzak, E. Ocampo, Incidence and implication of vocal fold paresis following neonatal cardiac surgery, The Laryngoscope 122 (2012) 2781–2785, https://doi.org/10.1002/lary.23575. [2] W.A. Clement, H. El-Hakim, E.Z. Phillipos, J.J. Coté, Unilateral vocal cord paralysis following patent ductus arteriosus ligation in extremely low-birth-weight infants, Arch. Otolaryngol. Head Neck Surg. 134 (2008) 28–33, https://doi.org/10.1001/ archoto.2007.2. [3] R.I.S. Zbar, A.H. Chen, D.M. Behrendt, E.F. Bell, R.J.H. Smith, Incidence of vocal fold paralysis in infants undergoing ligation of patent ductus arteriosus, Ann. Thorac. Surg. 61 (1996) 814–816, https://doi.org/10.1016/0003-4975(95) 01152-8. [4] K.D. Pereira, B.D. Webb, M.L. Blakely, C.S. Cox, K.P. Lally, Sequelae of recurrent laryngeal nerve injury after patent ductus arteriosus ligation, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 1609–1612, https://doi.org/10.1016/j.ijporl.2006.05. 001. [5] J.R. Benjamin, P.B. Smith, C.M. Cotten, J. Jaggers, R.F. Goldstein, W.F. Malcolm, Long-term morbidities associated with vocal cord paralysis after surgical closure of a patent ductus arteriosus in extremely low birth weight infants, J. Perinatol. 30 (2010) 408–413, https://doi.org/10.1038/jp.2009.124. [6] M.L. Skinner, L.A. Halstead, C.S. Rubinstein, A.M. Atz, D. Andrews, S.M. Bradley, Laryngopharyngeal dysfunction after the Norwood procedure, J. Thorac. Cardiovasc. Surg. 130 (2005) 1293–1301, https://doi.org/10.1016/j.jtcvs.2005.07. 013. [7] K. Averin, K. Uzark, R.H. Beekman, J.P. Willging, J. Pratt, P.B. Manning, Postoperative assessment of laryngopharyngeal dysfunction in neonates after Norwood operation, Ann. Thorac. Surg. 94 (2012) 1257–1261, https://doi.org/10. 1016/j.athoracsur.2012.01.009. [8] F.A. Alfares, C.F. Hynes, G. Ansari, R. Chounoune, M. Ramadan, C. Shaughnessy, B.K. Reilly, D. Zurakowski, R.A. Jonas, D.S. Nath, Outcomes of recurrent laryngeal nerve injury following congenital heart surgery: a contemporary experience, J. Saudi Hear. Assoc. 28 (2016) 1–6, https://doi.org/10.1016/j.jsha.2015.05.002. [9] B.M. Henry, W.C. Hsieh, B. Sanna, J. Vikse, D. Taterra, K.A. Tomaszewski, Incidence, risk factors, and comorbidities of vocal cord paralysis after surgical closure of a patent ductus arteriosus: a meta-analysis, Pediatr. Cardiol. 40 (2019)
4
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Point of care, clinician-performed laryngeal ultrasound and pediatric vocal fold movement impairment
T
Wynne Q. Zhanga, Elton M. Lambertb,c, Julina Ongkasuwanb,c,∗ a
Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA Texas Children's Hospital, Pediatric Otolaryngology, 6701 Fannin, Mark Wallace Tower, Suite 540, Houston, TX, 77030, USA c Baylor College of Medicine, Department of Otolaryngology Head and Neck Surgery, 1977 Butler St., 5th floor, Houston, TX, 77030, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Laryngeal ultrasound Vocal fold motion impairment Vocal fold paralysis Pediatric Vocal cord paralysis
Introduction: Vocal fold movement impairment (VFMI) is a well-known sequela of cervical and thoracic procedures performed in the vicinity of the recurrent laryngeal nerve. Interpretation of flexible nasolaryngoscopy (FNL) can be difficult in young children due to crying, secretions, and obstructing supraglottic structures. We have previously published on the use of radiologist performed and interpreted, laryngeal ultrasound (LUS) to evaluate vocal fold mobility with substantial agreement with FNL in infants in the cardiovascular intensive care unit. The purpose of this study was to evaluate point of care, clinician performed, LUS for vocal fold mobility in a pediatric voice clinic. Methods: LUS and FNL were performed and recorded on 30 consecutive patients (11 with a clinical diagnosis of VFMI and 19 with clinically normal mobility) in a pediatric voice clinic. All LUS was performed by a single clinician (reviewer 1) with a GE logiq P9 and 12 MHz linear probe. Deidentified recordings of the LUS and FNL (without sound) were reviewed in random order by 2 fellowship trained pediatric otolaryngologists who were blinded to the vocal fold mobility. Cohen's kappa was used to determine agreement. Results: There was substantial agreement (κ = 0.7) between the reviewers regarding interpretation of LUS as well as regarding interpretation of FNL κ = 0.7802. In addition, each reviewer had near perfect to substantial agreement between their interpretation of the LUS and FNL (reviewer 1 κ = 0.9294 and reviewer 2 κ = 0.8413). Conclusion: Point of care, clinician performed, LUS can be used for the identification of VFMI with substantial agreement with FNL with good inter-rater reliability. This provides clinicians with another tool in their armamentarium for the evaluation of challenging larynges.
1. Introduction Vocal fold movement impairment (VFMI) is a known sequela of cervical and thoracic surgeries due to the long circuitous route of the recurrent laryngeal nerve,. The reported incidence of VFMI following pediatric cardiac surgery varies from 1.1% to 67% [1–8], depending on the patient population and whether screening was performed on all patients postoperative patients versus r symptomatic ones. A pooled estimate of 33 studies suggests an incidence of 7.9% following surgical closure of patent ductus arteriosus [9]. In a systematic review of studies that excluded isolated patent ductus arteriosus closure to focus open cardiac surgery, rates of VFMI diagnosis ranged from 8 to 59% [10]. Unilateral VFMI can result in dysphagia and/or a weak and breathy voice, and stridor in some infants. Currently the standard for diagnosis of VFMI is flexible ∗
nasolaryngoscopy (FNL). However, in children, FNL can be challenging and inexact due to cooperation, secretions, and obstructing supraglottic structures. In addition, FNL can cause significant physiologic changes in blood pressure, heart rate and oxygen saturation, which can be a particular concern in vulnerable groups such as congenital heart disease and pulmonary hypertension [11,12]. It has also been shown that without sound to aid diagnosis, there was only moderate interrater reliability for identification of the degree of vocal fold movement in infants (k = 0.49) [13]. Transcervical laryngeal ultrasound (LUS) is an alternate way of assessing vocal fold mobility, which causes fewer changes in physiologic parameters. LUS was first described by Garel et al., in 1990. In 1997, Friedman published its use for identification of VFMI in children with agreement between the two modalities in 87–94% of cases with a minimum weighted k value of 0.75. Since then, other groups have
Corresponding author. Texas Children's Hospital, Pediatric Otolaryngology, 6701 Fannin, Mark Wallace Tower, Suite 540, Houston, TX, 77030, USA. E-mail addresses: [email protected] (W.Q. Zhang), [email protected] (E.M. Lambert), [email protected] (J. Ongkasuwan).
https://doi.org/10.1016/j.ijporl.2019.109773 Received 16 August 2019; Received in revised form 29 October 2019; Accepted 4 November 2019 Available online 09 November 2019 0165-5876/ © 2019 Elsevier B.V. All rights reserved.
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109773
W.Q. Zhang, et al.
Fig. 1. Laryngeal ultrasound.
digital flexible rhinolaryngoscope (Karl Storz Tuttlingen, Germany) in older children. Deidentified recordings of the LUS and FNL (without sound) were reviewed in random order by two fellowship trained pediatric otolaryngologists who were blinded to the vocal fold mobility. Qualitative mobility was reported as normal vs. VFMI (Fig. 1). For each reviewer, Cohen's kappa was used to determine agreement between interpretation of LUS and FNL. Cohen's kappa was also used to evaluate inter-rater agreement in interpretation of LUS.
explored the use of radiologist-performed LUS in assessment of vocal fold mobility. In 2004, Vats et al. found LUS to be in concordance with FNL 81.2% of the time in their sample of 55 patients ages three days to 12 years. In 2011, Wang et al. [14] further described identifying VFMI on LUS through criteria including abnormal mobility, asymmetry of structures, and flaccidity of the vocal fold, and reported high agreement (k = 0.96) between findings on FNL and LUS. In 2017, we published our experience at Texas Children's Hospital with radiologist-performed and interpreted laryngeal ultrasound (LUS) compared to FNL in patients in the pediatric cardiovascular intensive care unit [12]. We used measurements of the arytenoid-vocal fold angle in adduction and abduction. In 2018, Lee et al. reported that LUS had a 95% sensitivity and 88% specificity compared to FNL in identifying VFMI in a population of 52 pediatric patients following aortic arch repair [15]. While these prior studies have relied on radiologists or trained imaging specialists, increasingly portable and affordable ultrasound technology has led the drive to explore further applications of LUS as a point of care, clinician-performed exam. In recent years, the use of perioperative surgeon-performed LUS evaluation of vocal fold mobility has been explored in the adult population [16], and in 2015, Wong et al. showed that surgical residents trained to identify VFMI via LUS in adult patients could be considered competent following 7 ultrasound examinations and experienced after 40 [17]. Our goal in this study was to evaluate the use of LUS as a point of care, otolaryngologist-performed assessment of vocal fold movement in the pediatric population.
3. Results Thirteen of the patients were female and 17 were male. Ages ranged from 3 months to 17 years with a median age of 4 years and 6 months. Reasons for referral and clinical vocal fold mobility findings are listed in Table 1. Interrater agreement regarding interpretation of LUS was κ = 0.7 and for interpretation of FNL was κ = 0.7802. In addition, each reviewer had near perfect to substantial agreement between their own interpretation of the LUS and FNL (reviewer 1 κ = 0.9294 and reviewer 2 κ = 0.8413). Raw data is shown in Table 1 with non-congruent results highlighted in grey. 4. Discussion In this study we aimed to show that qualitative interpretation of LUS can be used by clinicians to evaluate vocal fold mobility. Our previous work used quantitative measurements of vocal fold – arytenoid angles to determine mobility. However, often clinicians do not have the time or inclination to perform these measurements. Qualitative interpretation of LUS is, in fact, similar to the way in which most otolaryngologists are accustomed to interpreting FNL. As we observed in our previous study, the vocal fold edge and thus glottic closure is difficult to assess with LUS. Because of its density, arytenoid rotation is the easiest structure to appreciate. Our results are comparable to those of previous studies that used radiologists, with reported kappa values for comparison of LUS to FNL ranging from 0.75 to 0.96 [14,15,18]. This suggests that the transition of LUS to a clinician-performed exam at bedside or in clinic will not sacrifice the accuracy of the test. It should be noted that there were instances in which the reviewers' interpretations of the FNL recordings were not congruent with each other (in a blinded context) or with the initial, in clinic, FNL and
2. Material and methods With Institutional Review Board Approval, LUS and FNL were performed and recorded on 30 consecutive patients (11 with a clinical diagnosis of VFMI and 19 with clinically normal mobility at the time of FNL and LUS) in a pediatric voice clinic. Diagnosis of VFMI and resultant categorization for the study was determined by the clinical, in office, impression based on FNL findings. All LUS was performed by a single clinician (reviewer 1) on the same day as the FNL with a GE logiq P9 ultrasound and 12 MHZ linear probe (GE Healthcare, Boston, MA). The patients were positioned typically in a parent's lap with the neck in extension. Ultrasound was performed with probe placed over the cricothyroid membrane angled slightly superiorly. The probe was orientated such that the right vocal fold was on the left side of the screen. FNL was performed with an Olympus ENF-XP 2.2 mm flexible fiber laryngoscope in infants (Olympus Tokyo, Japan) and Karl Storz 3.7 mm 2
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109773
W.Q. Zhang, et al.
Table 1 Patient demographics and reviewer Data.
provides additional information that may aid in diagnosis of VFMI in patients who cannot undergo FNL.
examination. The imperfect agreement between the reviewers regarding the recorded FNL's is consistent with our previously published data [13]. This is a relatively small study performed at a single institution, largely by a single clinician, reviewer 1, thus limiting its generalizability. However, because LUS interpretation is relatively intuitive to clinicians accustomed to viewing FNL, reviewer 2 was able interpret the LUS without any direct instruction. In additional, LUS cannot assess supraglottic or subglottic structures as part of the evaluation of stridor.
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest 5. Conclusions The authors have no financial interest or conflicts of interest to disclose.
The portability, ease of use, lack of radiation, low cost and dynamic imaging capabilities of LUS make it a useful addition to the clinical repertoire of the otolaryngologist. LUS is well tolerated by patients and 3
International Journal of Pediatric Otorhinolaryngology 129 (2020) 109773
W.Q. Zhang, et al.
References
116–125, https://doi.org/10.1007/s00246-018-1967-8. [10] S. Orzell, R. Joseph, J. Ongkasuwan, J. Bedwell, J. Shin, N. Raol, Outcomes of Vocal Fold Motion Impairment and Dysphagia after Pediatric Cardiothoracic Surgery: A Systematic Review, (2019), https://doi.org/10.1177/0194599819858594. [11] J. Ongkasuwan, K.C. Yung, M.S. Courey, The physiologic impact of transnasal flexible endoscopy, The Laryngoscope 122 (2012) 1331–1334, https://doi.org/10. 1002/lary.23358. [12] J. Ongkasuwan, E. Ocampo, B. Tran, Laryngeal ultrasound and vocal fold movement in the pediatric cardiovascular intensive care unit, The Laryngoscope 127 (2017) 167–172, https://doi.org/10.1002/lary.26051. [13] Y.C.C. Liu, T. McElwee, M. Musso, T.L. Rosenberg, J. Ongkasuwan, The reliability of flexible nasolaryngoscopy in the identification of vocal fold movement impairment in young infants, Int. J. Pediatr. Otorhinolaryngol. 100 (2017) 157–159, https:// doi.org/10.1016/j.ijporl.2017.07.005. [14] L.M. Wang, Q. Zhu, T. Ma, J.P. Li, R. Hu, X.Y. Rong, W. Xu, Z.C. Wang, Value of ultrasonography in diagnosis of pediatric vocal fold paralysis, Int. J. Pediatr. Otorhinolaryngol. 75 (2011) 1186–1190, https://doi.org/10.1016/j.ijporl.2011.06. 017. [15] M.G.Y. Lee, J. Millar, E. Rose, A. Jones, D. Wood, T.L. Luitingh, D. Zannino, J. Brink, I.E. Konstantinov, C.P. Brizard, Y. d'Udekem, Laryngeal ultrasound detects a high incidence of vocal cord paresis after aortic arch repair in neonates and young children, J. Thorac. Cardiovasc. Surg. 155 (2018) 2579–2587, https://doi.org/10. 1016/j.jtcvs.2017.12.133. [16] K.P. Wong, B.H.H. Lang, S.H. Ng, C.Y. Cheung, C.T.Y. Chan, C.Y. Lo, A prospective, assessor-blind evaluation of surgeon-performed transcutaneous laryngeal ultrasonography in vocal cord examination before and after thyroidectomy, Surgery (St Louis) 154 (2013) 1158–1165, https://doi.org/10.1016/j.surg.2013.04.063. [17] K.P. Wong, B.H.H. Lang, S. Lam, K.P. Au, D.T.Y. Chan, N.C. Kotewall, Determining the learning curve of transcutaneous laryngeal ultrasound in vocal cord assessment by CUSUM analysis of eight surgical residents: when to abandon laryngoscopy, World J. Surg. 40 (2016) 659–664, https://doi.org/10.1007/s00268-015-3348-2. [18] E.M. Friedman, Role of ultrasound in the assessment of vocal cord function in infants and children, Ann. Otol. Rhinol. Laryngol. 106 (1997) 199–209 http://www. embase.com/search/results?subaction=viewrecord&from=export&id= L27123210.
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