Efficacy of videostroboscopy in the diagnosis of voice disorders -

ROY R. CASIANO, MD, VIJAYKUMAR ZAVERI, MD, and DONNA S. LUNDY, MA, CCC, Miami, Florida

While videostrobolaryngoscopy is not a new technique, its acceptance as a routine part of the voice evaluation has not been as forthcoming. Many are in agreement that the rigid fiberoptic telescopes in combination with standard VHS equipment provide a clear, magnified image that can be recorded and used for pretreatment and posttreatment comparisons, documentation,teaching, and research. Yet, some skepticism persists with regard to the ability of videolaryngoscopy and/or videostrobolaryngoscopy in changing the diagnosis and treatment outcome of patients with voice disorders as compared to indirect laryngoscopy. Two hundred ninety-two dysphonic patients were identified who underwent indirect as well as videolaryngoscopy with and without stroboscopic examination. Videostrobolaryngoscopy was found to alter the diagnosis and treatment outcome in 14% of the patients. It is most useful in patients with a diagnosis of functional dysphonia and vocal fold paralysis by indirect laryngoscopy. The increased illumination and magnification afforded by rigid fiberoptic telescopes during videolaryngoscopy, combined with the detailed assessment of glottic closure, mucosal wave, and amplitude characteristics provided by stroboscopic examination, allowed detection of subtle vocal fold pathology, otherwise missed by indirect laryngoscopy. (OTOLARYNGOL HEAD NECK SURG 1992;107:95)

S i n c e its introduction into the American clinical arena in the mid 1980’s, videostrobolaryngoscopy (VSL) has rapidly become a widely used and accepted component for the comprehensive evaluation of voice disorders. Many authors have noted its superiority to simple indirect laryngoscopy by allowing a more detailed and objective analysis of vocal fold vibratory characteristics. ’ ~ When ’ coupled with standard video recorders, the information gained may be subsequently reviewed and analyzed. This has been of some value, particularly in the areas of research, patient and resident education, and medical records documentation. However, in spite of this current enthusiasm regarding the use of VSL, there remain some unanswered questions regarding the efficacy of stroboscopic light analysis in changing the clinical diagnosis and/or treatment of patients with

From the Department of Otolaryngology, University of Miami School of Medicine. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Kansas City, Mo., Sept. 2226, 1991. Received for publication Sept. 23, 1991; revision received Jan. 28, 1992; accepted Feb. 12, 1992. Reprint requests: Roy R. Casiano, MD, Department of Otolaryngology, University of Miami School of Medicine, P.O. Box 016960. Miami. FL 33101.

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voice disorders when compared to indirect flexible or rigid telescopic evaluation of the larynx in the office setting. The purpose of this study is to examine the efficacy of VSL in terms of its ability to change the diagnosis and/ or treatment of patients who manifest with voice problems. Of particular interest is the use of rigid telescopic examination alone in establishing the diagnosis or changing the course of treatment without stroboscopic examination. From this it is hoped that specific criteria can be developed from which the clinician can comfortably predict which patients will benefit most from VSL analysis. METHODS AND MATERIAL

Three hundred seventy-five patients underwent VSL, performed by the senior authors from October 1988 to July 1990. Of these, 292 patients had a complete otolaryngologic evaluation at our institution before VSL. On review of the prestroboscopic diagnoses by indirect laryngoscopy, four broad groups of patients were identified (see Table 1). They were classified as patients with benign vocal fold lesions (group I), malignant vocal fold lesions (group II), neuromuscular/ skeletal disorders of the larynx (group III), or functional disorders of the larynx (group IV). The latter group included all patients who continued to have voice problems despite normal indirect laryngoscopy. There were

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95

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96 CASLANO ef al

Table 1. Prestobolaryngoscopy diagnoses N (“A)

1. Benign vocal fold les/ons Polyps Nodules Polypoid corditis Glottic stenosis cyst Hemorrhage Erythema Acute laryngitis Chronic laryngitis Reflux laryngitis lntubation granuloma Laryngeal candidiasis Contact ulcerigranuloma Papillomas Subglottic mass Lesions (unknown) 11. Malignant vocal cord lesions Carcinoma Leukoplakiai Hyperkeratosis Erythroplasia 111. Neuromusculari Skeletal Disorders Paralysis Dystonia Cricoarytenoid joint fixation Essential tremor Laryngospasm Bowing Presbylarynx Superior laryngeal nerve palsy IV. Funcrional dysphonia (WNL) Normal examination Plica Mutational falsetto Muscular tension dysphonia TOTAL PATIENTS

Table 2. Stroboscopy Parameters

Mucosal appearance Vocal fold edges Vertical level of the glottic plane Supraglottic activity Vocal fold mobility Glottic closure Amplitude Mucosal wave Symmetry of vibration (phase) Periodicity

98 (34) 32 22 10 5 1 4 2

Change in primary DX N (“A) 19

7 3 1 1

102 (34) 57 25 6 2 1 7 3 1 71 (24) 64 2 2 3 292

24 (25) 4 4

5 1

3 2

1 1

3 1

2

2 8 3 4 1 1 1 1 1 21 (7) 14 6 1

Additional findings N (“A)

2 1

I

1 (5)

9 8 1

1

3 (0.3) 3

26 17 4 2 1 1

31 (44) 31

1 12 (17) 11

-

-1

54

71

98 patients in group I, 21 in group 11, 102 in group 111, and 71 in group IV. There were 136 men and 156 women. The average age was 50 years, with a range from 5 to 85 years. VSL was performed using a 90-degree Wolf rigid telescope coupled with a Panasonic video monitor and a Bruel-Kjaer stroboscope unit (Bruel-Kjaer, Boston, Mass .). All images were recorded on a Panasonic video cassette recorder. Patients who were unable to undergo a rigid telescopic evaluation were evaluated with an Olympus flexible fiberoptic laryngoscope (Olympus Corp., New York, N.Y.). Topical anesthetic was avoided unless the patient exhibited extreme gagging

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Efficacy of videostroboscopy in diagnosis of voice disorders 97

and/or if fiberoptic nasolaryngoscopy was necessary. Interpretation of the data was graded according to standard parameters as published elsewhere and listed in Table 2.’ When stroboscopy was difficult, the reason for such difficulty was recorded. Patients’ records and videotape recordings were critically reviewed for a change in their primary diagnoses or the presence of additional findings by VSL. A change in one or more stroboscopic parameters was not considered an additional finding unless it resulted in a change in the clinical diagnosis (separate from the primary diagnosis). A determination was made as to whether the stroboscopic parameter was necessary in making the new diagnosis or if it merely confirmed or improved the clinical assessment on the basis of the rigid telescopic or flexible fiberoptic findings. Any change in treatment from that recommended before VSL was also noted. RESULTS

Fifty-four patients (19%) had a change in their primary diagnosis on the basis of their VSL (Table 1). The diagnosis changed in 44% of the patients in group IV, 20% in group I, 5% in group 11, and 3% in group 111. The vast majority, or 70%, of the 54 patients who had a change in their primary diagnosis were diagnosed as having benign vocal fold lesions by VSL (Table 3 ) . Included in this list were patients who exhibited vocal fold stiffness as a result of previous vocal fold surgical procedures and/or acute blunt or penetrating trauma. Nineteen percent of the patients were diagnosed by videostrobolaryngoscopy as having a neuromuscular or skeletal disorder. The most common of these was presbylarynx and/or vocal fold bowing. Four patients (17%) were reclassified as functional. One patient who was thought to have a right vocal cord paralysis by indirect laryngoscopy had a normal videostrobolaryngoscopic examination. Two patients had plica ventricularis and one patient was diagnosed as having muscle tension dysphonia despite a normal indirect laryngosocpic examination. The latter diagnosis was made on the basis of a medical history of voice abuse combined with stroboscopic parameters, suggesting vocal fold stiffness in addition to mild erythema by rigid telescopic examination under regular light. ‘ There were 77 additional findings made on 71 patients (24%). Additional findings were most commonly found in patients with malignant vocal cord lesions by indirect laryngoscopy (Table 1). Patients with a prestroboscopic diagnosis of benign vocal fold lesions, neuromuscular/ skeletal disorder, and functional dys-

phonia had additional lesions noted in fairly equal numbers. Benign lesions were found by VSL in 82% of these patients (Table 3). Neuromuscular or skeletal disorders were found in 17%. Of these, vocal fold paralysis and/or bowing were commonly seen, despite a normal or an inadequate indirect laryngoscopic examination. Three patients (4%) had an additional diagnosis of hyperkeratosis or leukoplakia. Planned treatment was changed as the result of a change or modification in primary diagnosis in 31 (1 1%) of the total patients. Conservative treatment was recommended for twenty-two patients who had no previous treatment, despite multiple visits to otolaryngologists. This included voice therapy, voice coaching, anti-reflux regimen and/or hydration plan. Surgery was recommended in nine patients. Six patients underwent microlaryngoscopy and biopsy or removal of their vocal fold lesion. Two patients underwent reduction of their arytenoid dislocation. One patient underwent vocal fold medialization through a thyroplasty type I approach for incomplete glottic closure secondary to unilateral bowing. One patient with vocal tremor was referred to neurology for further evaluation. Individual stroboscopic parameters were analyzed as to their usefulness in establishing, changing, or modifying the primary diagnosis and/or treatment. There were mucosal wave and/ or amplitude abnormalities in 110 patients. A change was made in the primary diagnosis in only 13 patients (5%). Eleven patients with vocal fold stiffness as a result of previous trauma or surgery and two patients with muscular tension dysphonia were recommended to have voice therapy. The presence of aperiodicity and/or asymmetry on its own did not effect a change in diagnosis in any patients. However, aperiodicity and/or asymmetry was noted in a number of patients who exhibited difficulties in maintaining a steady glottic air flow, either from inadequate pulmonary support, movement disorders of the larynx, or incomplete glottic closure from vocal fold paralysis. Twenty-five patients (9%) with vocal fold paralysis had a change in treatment and were advised to undergo vocal fold medialization surgery on the basis of stroboscopic findings. All of them improved with surgery. Stroboscopic light significantly improved the assessment of glottic closure in all of these patients. Complete glottic closure was noted in some patients who were thought to close completely on the basis of direct laryngoscopic or telescopic examination alone. Conversely, other patients thought to have complete glottic closure by telescopic light were found to have incomplete glottic closure under stroboscopic analysis. All of these patients

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98 CASlANO et al.

Table 3. New primary diagnoses and additional findings

l Benign vocal fold lesions Polyps Nodules Polypoid corditis Reinke’s edema cyst Hemorrhage Reflux laryngitis Papillomas Web Hypertrophy false fold Subglottic stenosis Contact ulcers Hypervascularity/telangiectatic vessels Prominent vocal fold lntubation granuloma Sulcus vocaiis Avulsed vocal fold Subluxed/dislocated arytenoid Lesion (unknown) Stiffness secondary to trauma / I Malignant vocal fold lesions Glottic/subglottic mass Carcinoma Hyperkeratosis/Leukoplakia 111 Neuromuscularl Skeletal Disorders Paralysis/paresis Myoclonic movement Abnormal vocal fold position Presbylarynx Bowing Superior laryngeal nerve palsy Tremor l V Functional Normal Plica Muscular tension dysphonia TOTAL DIAGNOSES

Primary N (“10)

Additional N (“A)

38 (70) 7 2 6

58 (82)

6 3 18 6 3

1

1 3 (4)

3 10 (19)

12 (17) 2 1 1

5 2

8

2 1

4 (7) 1 2 1 54

4

-

Based on rigid telescope alone

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes No Yes No

77

Unsatisfactory stroboscopic examination was noted were believed to be amenable to vocal fold medialiin 99 patients (34%). The most common reasons for zation. incomplete examination were increased breathiness or Flexible fiberoptic examination was necessary in 14 inability to maintain a steady tone to trigger the strobe patients (5%). Patients who were severe gaggers or in light, and decreased phonation time, which limited the whom the anterior glottis was not visualized with the time necessary to analyze the stroboscopic parameters.’ rigid telescope were more apt to require fiberoptic exOther difficulties included poor visualization as a result amination. The quality of nonstroboscopic images apof prominent secretions, increased gag or supraglottic proach but never reach that of a rigid telescopic exactivity, poor patient cooperation, inability to eliminate amination. However, stroboscopic light examination artistic vibrato, and/or large lesions (i.e., polyps) obwith a flexible fiberoptic laryngoscope was far more structing adequate viewing of the glottis. limited than that performed with rigid telescopes. When a flexible fiberoptic laryngoscope is coupled with stroDISCUSSION boscopic light, it is important to visualize the folds The use of stroboscopy for laryngeal analysis is not completely by bringing theDownloaded scopefrom directly on top of the oto.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on July 12, 2015 new. It was first described by Oerte16 in 1895. In 1932, vocal folds to maximize illumination and magnification.

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Efficacy of videostroboscopy in diagnosis of voice disorders 99

viewing the videotape recordings, differentiation of voKallen’ explained the surgical and optical properties of cal fold nodules from polyps or cysts was made possible stroboscopic light when used to evaluate vocal fold by telescopic examination in most cases. In some cases, motion. The ability of the unaided eye to perceptually however, stroboscopic light further improved clinical see vocal folds vibrate in slow motion was based on assessment and confirmed early and sometimes subtle the fact that the naked eye can perceive no more than vocal fold nodules and cysts suspected by telescopic five distinct images per second. The image lingers on examination but not clearly seen. Rigid telescopic evalthe retina for 0.2 seconds after exposure. Using a pulsed uation suggested the presence of these lesions by the (strobe) light source to illuminate segments of vocal typical hourglass appearance of glottic closure. Cysts fold motion, the eye fuses the images into what it sees are seen as submucosal fluid-filled sacs, in contrast to as an illusion of slow motion. In truth, what actually nodules or polyps. is seen are illuminated points along successive phoPatients went to surgery on the appearance of the natory cycles, which are fused to provide an average lesion by regular light examination, regardless of the vibratory pattern. In 1961, von Leden* described the stroboscopic findings. The presence of a mucosal wave use of “electronic” stroboscopy as a potential diagnostic or amplitude did not dissuade the laryngologist to peroffice tool in the management of voice disorders. It did form a biopsy on a potentially malignant lesion. Despite not gain clinical acceptance until the mid-l980’s, when the stroboscopic findings and regardless of the depth of further technological advancements made it practical to invasion into the vocalis muscle, T, lesions with normal assess vocal fold vibrations by stroboscopy. Today, ascord mobility by telescopic analysis were treated with sessment of a number of stroboscopic parameters in radiation therapy. Conversely, the absence of these pastandard format continues to increase our understanding rameters did not necessarily lead to surgery if the lesion and makes critical evaluation of the vibratory characwas clearly benign (i.e., hemorrhage, stiffness resulting teristics of the vocal folds possible.2 from previous trauma, intracordal cysts, etc.) . Despite its recent popularity, there remains continued reluctance on the part of many otolaryngologists to acOur results also suggest that for the trained laryncept VSL. This is due, in part, to a great deal of skepgologist who is familiar with a wide variety of voice ticism regarding its efficacy in the diagnosis of voice disorders, magnified telescopic examination of the lardisorders as compared to standard ways of evaluating ynx alone may enhance the evaluation of vocal fold voice problems (i.e., indirect laryngoscopy and/or perpathology beyond that which may be expected from ceptual voice analysis). Also, the expense of the stroindirect laryngoscopy alone. We have also found that boscopic and video equipment is still high. The majority telescopic examinations have improved our indirect of this cost is for the stroboscopic light unit alone. mirror examination of the larynx. These findings are Today, in an age of cost-conscious consumers and third supported by Bastian et al.,” who in 1989 noted the party reimbursement, the ability of a new instrument use of office telescopic examination of the larynx for to improve diagnosis and/ or predict treatment outcome cancer staging to be equivalent to direct laryngoscopic after a given procedure becomes very important. The examination while the patient is under general anesthesia. The difference is analogous to that seen between issue of cost vs. benefits always seems to arise. anterior rhinoscopy and telescopic evaluation of the osMuch literature is available regarding the theoretical teomeatal complex in evaluation of sinus disease. The applications of strobolaryngoscopy for the diagnosis of combination of improved illumination, magnification, voice disorders. Some authors have commented on its and angle of inspection offered by the rigid telescopes efficacy in a high-volume laryngologic clinical setting. coupled with the ability to review images recorded on In 1991, Sataloff et al.9 studied the efficacy of VSL. videotape allowed detection of subtle changes on the Thirty-two percent of their 352 patients had a diagnostic vocal folds in most of our patients. This is of some change on the basis of stroboscopic evaluation. WOOet importance to the practicing otolaryngologist because al.’O reported a 10%change in diagnosis in their series. appropriate video-recording equipment and rigid teleIn addition, they reported a treatment change in 15 of scopes can be obtained for a fraction of the cost nectheir 146 patients (10%). Our results show a change in essary for a stroboscopic unit. diagnosis or additional findings in 43% of our patients. The fact that only 14% of our total study population However, approximately 90% of these patients had their had a change in primary diagnosis or treatment by strochange in diagnosis and/or additional findings detected boscopy should not mislead one to underrate the value by telescopic evaluation alone. With the exception of of stroboscopy in the management of patients with voice sulcus vocalis, vocal fold stiffness resulting from disorders. VSL was useful in planning medical and/or trauma, and vocal fold paralysis or bowing, virtually surgical treatment for a number of patients. It improved all of the changes in diagnosis and/or treatment were clinical assessment during the treatment of benign made by rigid telescopic evaluation alone under regular Downloaded from oto.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on July 12, 2015 and/or malignant vocal fold lesions. The clinician now light without stroboscopic analysis (Table 3 ) . In re-

OtolaryngologyHead and Neck Surgery

can follow progressive improvement in glottic closure, mucosal wave, amplitude, etc. Even in those patients not consenting or amenable to medical or surgical treatment, stroboscopic evaluation explained the patient’s problems and confirmed the observation of a harsh or breathy-sounding vocal quality. The ability to perform a stroboscopic light examination was not without limitation. Woo et al.” reported 18% equivocal stroboscopies in their series of patients. Thirty-four percent of our patients exhibited too much supraglottic activity, increased secretions, large polyps, and/ or poor patient cooperation made prolonged visualization of the vocal folds difficult to analyze by stroboscopic light. Also, patients with a high degree of breathy voice and incomplete glottic closure, and/ or inability to maintain a constant, steady phonation for at least 2 to 3 seconds limited stroboscopic evaluation. This was because of the inability of the instrument to key into a specific fwdamental frequency on these patients. In conclusion, VSL is helpful in establishing a diagnosis and/or improving the clinical assessment of patients with voice disorders. Patients with persistent dysphonia despite normal or equivocal indirect laryngoscopic findings, and patients with vocal fold paralysis and/or bowing, seem to benefit most from VSL. Diagnostic and/or treatment changes occurred most often in these groups of patients. Although stroboscopic analysis improved the clinical assessment of benign and malignant vocal fold lesions, as well as other neuromuscular/ skeletal disorders of the larynx, most were detected by careful rigid telescopic examination under regular light. Rigid telescopic examination is superior to indirect laryngoscopy alone in establishing a diagnosis for a

significant number of patients with suspected endolaryngeal pathology. Patient selection criteria for VSL will undoubtedly be modified with continued experience and further advancements in technology and in the medical and/or surgical treatment of voice disorders. As with many other tests or procedures, however, VSL on its own has certain limitations the clinician must recognize. As part of an overall battery of objective tests, VSL can provide information that is crucial to the comprehensive evaluation and management of patients with voice disorders. REFERENCES

I . Sataloff RT, Spiegel J, Carroll L. Objective measures of voice function. Ear Nose Throat J 1987;66:307-12. 2. Bless DM, Hirano M, Feder RJ. Videostroboscopic evaluation of the larynx. Ear Nose Throat J 1987;66:289-96. 3. Gould WJ, Kojima H, Lambiase A. A technic for stroboscopic examination of vocal folds using fiberoptics. Arch Otolaryngol Head Neck Surg 1979;105:285. 4. Alberti PW. The diagnostic role of laryngeal stroboscopy. Otolaryngol Clin North Am 1978;11:347-54. 5 . Hirano M, Yoshikazu Y , Tetsuji Y , Osamu T. Strobofiberscopic video recording of vocal fold vibration. Ann Otorhinolaryngol 1985;94:588-90. 6. Oertel MJ. Das Laryngostroboskop Und die Untersuchung. Arch Otol Rhinol Laryngol 1895;3:1-16. 7. Kallen 1A. Laryngostroboscopy in the practice of otolaryngology. Arch Otolaryngol 1932;6:791-807. 8. von Leden H. The electronic synchron-stroboscope. Ann Otol Rhinol Laryngol 1961;70:88 1-93. 9. Sataloff RT, Spiegel J, Hawkshaw MJ. Strobovideolaryngoscopy: Results and clinical value. Ann Otol Rhinol Laryngol 1991;100:725-7. 10. Woo P, Colton R, Casper J , Brewer D. Diagnostic value of stroboscopic examination in hoarse patients. J Voice 1991;5: 231-8. 11, Bastian RW, Collins SL, Kaniff T, Matz J. Indirect videolayngoscopy versus direct endoscopy for larynx and pharynx cancer staging. Ann Otol Rhinol Laryngol 1989;98:693-8.

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Otolaryngology Head and Neck Surgery March 1993

News and Announcements

held July 26-30, 1993, at the Tamarron Resort in Durango, Colorado. This 28 hour review and update will encompass all the clinically important areas of MR imaging. Important new concepts and pathological/imaging correlations in the body, musculoskeletal system, ENT, head and neck, brain, and spine will be explored. Daily case presentations will supplement these lectures and will serve to test the registrants' diagnostic abilities in MR imaging. This complete review of MR imaging will be presented by nationally recognized leaders in magnetic resonance imaging. As a result of this comprehensive review, registrants will become familiar with current applications of MR imaging and will be able to integrate many of these applications directly into their practice. Program chairmen for this presentation will be Robert Quencer, MD (University of Miami), Victor Haughton, MD (Medical College of Wisconsin). Twenty-eight credits of Category I will be available. For further information, please contact Marti Carter, CME, Inc., 11011 West Nort Ave., Milwaukee, Wisconsin 53226, or call (414) 771-9520. Ear, Nose, and Throat Diseases: 1993 Update

Children's Hospital of Pittsburgh will hold its 18th Annual Symposium, "Ear, Nose, and Throat Diseases in Children: A 1993 Update." This symposium will be held July 30-31, 1993. CME credits will be awarded.

For further information, please contact the Department of Pediatric Otolaryngology, Children's Hospital of Pittsburgh, 3705 Fifth Avenue at DeSoto St., Pittsburgh, Pennsylvania 15213, or call (412) 692-8577. Twenty-fifth Annual Meeting - Head and Neck Oncologists

The Association of Head and Neck Oncologists of Great Britain will sponsor the Twenty-fifth Annual Meeting of Head and Neck Oncology, to be held in Edinburgh, Scotland, United Kingdom, on August 23-26, 1993. International and local faculty will present extensive social and family programs. For further information, please contact Mr. P. J. Bradley, Honorary Secretary, Department of Otorhinolaryngology-Head and Neck Surgery, University Hospital, Queens Medical Centre, Nottingham, NG7 2UH, England, or phone 0602421421. Sixth International Congress on Interventlonal Ultrasound

The Sixth International Congress on Interventional Ultrasound will be held in Copenhagen, Denmark, on September 7-10, 1993. For further information, please contact Christian Nolsoe, Congress Secretary, Department of Ultrasound, Herlev Hospital, University of Copenhagen, DK-2730 HerlevDenmark, or call + 45/ 44 53 53 00 ext. 3240.

CORRECTION

The Supplement to the December 1992 issue of the JOURNAL (Volume 107, Number 6, Part 2), incorrectly listed Dr. Bruce R. Gordon as Chief of Otolaryngology at the Massachusetts Eye and Ear Institute. Dr. Joseph Nadol is Chief of Otolaryngology at the Massachusetts Eye and Ear Infirmary. Dr. Gordon is Chief of Otolaryngology at Cape Cod Hospital.