Ann Otol Rhinol La ryngo1 100:1991
STROBOVIDEOLARYNGOSCOPY: RESULTS AND CLINICAL VALUE ROBERT JOSEPH
T. SATALOFF, MD
R. SPIEGEL, MD
MARY J. HAWKSHAW,
RN
PHILADELPHIA, PENNSYLVANIA
Strobovideolaryngoscopy is a valuable addition to the diagnostic armamentarium because it allows the otolaryngologist to perform a detailed physical examination of the vibratory margin of the vocal fold. From 1985 through 1989, we performed 1,876 strobovideolaryngoscopy procedures, the majority on professional voice users. Previously, we reported findings on our first 486 strobovideolaryngoscopy procedures. Stroboscopic information influenced diagnosis or treatment in approximately one third. The present study was undertaken to determine whether additional experience had altered the clinical usefulness of the procedure. Diagnoses were noted before and after stroboscopy prospectively for 377 strobovideolaryngoscopy procedures performed during the calendar year 1989. In 530/0 of the procedures, strobovideolaryngoscopy resulted in no change in diagnosis. In 29 %, preprocedure impressions were confirmed and additional diagnoses were made. In 180/0, preprocedure diagnoses were found to be incorrect. The procedure has proven very helpful in caring for voice patients, modifying diagnoses in 47 0/0, and confirming uncertain diagnoses in many of the other patients studied.
KEY WORDS - stroboscopy, strobovideolaryngoscopy, voice.
Complex motion of the vibratory margin of the vocal folds is essential for normal voice. Because the vocal folds open and close between about 60 and 1,500 times per second depending upon the pitch of phonation, valid, reliable physical examination of the vibratory margin cannot be accomplished by using continuous light and a laryngeal mirror. Highspeed photography permits slow-motion evaluation of vocal fold vibration, but it is cumbersome. It also permits evaluation of only relatively short samples of phonation. High-speed video is not widely available and shares many disadvantages with high-speed photography. Strobovideolaryngoscopy is currently the most convenient technique permitting the otolaryngologist to perform a detailed assessment of the vibratory margin of the vocal fold. From 1985 through 1989, we performed 1,876 strobovideolaryngoscopy procedures. All strobovideolaryngoscopic examinations were performed by an otolaryngologist, usually with the assistance of a nurse, speechlanguage pathologist, and/or singing voice specialist. The majority were on professional voice users. Previously, we reported findings on our first 486 strobovideolaryngoscopy procedures. 1 Stroboscopic information influenced diagnosis or treatment in approximately one third of cases. The present study was undertaken to determine whether additional experience had altered the clinical usefulness of the procedure.
ing which strobovideolaryngoscopy was performed comprised approximately 32 % of voice patient visits, and stroboscopy was performed on 60 % of the patients seen during that period. All patients were selected because of the presence or suspicion of a structural or neurologic abnormality, or to prove the absence of such a lesion. Of the 352 patients who underwent strobovideolaryngoscopy, the majority were professional voice users, and 129 of these were singers. The other patients also sought medical attention specifically for voice complaints. All stroboscopic examinations were performed with a Bruel and Kjaer rhinolarynx stroboscope type 4914, with the patient seated. An Olympus flexible nasolaryngoscope and a magnifying telescope were used in virtually all cases. Initially, examinations were performed while looking directly into the laryngoscope before connecting it to the video system. In some cases, the laryngoscope was also connected to a Zeiss operating microscope using a custommade adaptor, before strobovideolaryngoscopy. This technique provides high-quality magnification, which is especially helpful in those few patients who will not tolerate the laryngeal telescope. The flexible laryngoscope permits observation of vocal fold function under continuous and stroboscopic light during a variety of phonatory tasks, with relatively undistorted vocal tract anatomy. The magnification and high optical quality provided by a rigid laryngeal telescope are invaluable and obviate the need for magnification with an operating microscope in most cases. However, they permit vocal fold evaluation only during relatively awkward vocal tract positions and tasks. Simultaneous synchronized electroglottography was also performed, and the electroglottographic waveform
MATERIALS AND METHODS
Three hundred seventy-seven strobovideolaryngoscopy procedures were performed on 352 patients between January 1, 1989, and December 31, 1989. During that period, we saw 583 voice patients for a total of 1,180 voice-related visits. The 377 visits dur-
From the Department of Otolaryngology, Thomas Jefferson University (Sataloff, Spiegel), and the American Institute for Voice and Ear Research (Hawkshaw), Philadelphia, Pennsylvania. Presented at the meeting of the American Laryngological Association, Waikoloa, Hawaii, May 4-5, 1991. REPRINTS - Robert T. Sataloff, MD, 1721 Pine St, Philadelphia, PA 19103.
725
726
Satalojj et al, Strobovideolaryngoscopy
TABLE 1. FORTY ENTITIES OBSERVED DURING 377 STROBOVIDEOLARYNGOSCOPIC PROCEDURES Diagnosis Arytenoid dislocation Cancer Cricothyroid fusion Cysts Dysarthria Dysphonia Dysphonia plica ventricularis Functional dysphonia Th~~~~
Granuloma Hemorrhage Histoplasmosis Hoarseness Laryngeal spasm Laryngitis Leukoplakia Lymphoid hyperplasia Mass Mucosal tear Myasthenia gravis Nerve paralysis or paresis Nodules Nmmal Parkinson's disease ~yp
Presbyphonia Reflux laryngitis Reinke's edema Respiratory dysfunction Sarcoidosis Scar with stiffness Subglottic stenosis Temporomandibular joint syndrome Tonsillitis Trauma
No. of Procedures 2
No. of Patients 2
TABLE 2. NUMBER OF PROCEDURES EXPERIENCED BY INDIVIDUAL PATIENTS No. of Procedures per Patient 1
Patients No. %
4
3
2
326 23
1 10 1
1 8 1
3 4
1 2
50
45
8
5
9
9
1
1
3 30 1 2 7 21 2 2 87 6 3
3 26
66
1 2 2 18 1 1 86 6 3 59
34
32
7
5
1 6 12 186 10 1 1 59 1
1 4 10 165 4 1 1
1
1
32
1
1
1
4
3
~~
1
1
Upper respiratory tract infection Varicosity Voice abuse" VVeb
1
1
11 133 5
10 126 5
"Includes hypofunctional and hyperfunctional voice abuse, muscular tension dysphonia, and improper singing or speaking technique.
was superimposed on the laryngeal image. Electroglottography provides an assessment of each vibratory event. This is a valuable adjunct because the stroboscope only simulates slow motion by imaging fragments of successive vibratory cycles. All examinations were recorded on videotape and stored. Duplicates were made routinely for the referring physician, speech-language pathologist, singing teacher, or patient. Black and white and color video printers are also connected to the system for documentation and patient education. Our videostroboscopy protocol involves speaking at various frequencies and intensities, pitch sliding, sniffing, whistling, rapid repetition of syllables, singing, sustained vowel phonation, and other selected tasks. Observations are recorded about voice quality, laryngeal color, vocal fold motion, vibratory margin motion, structural abnormalities, supraglottic
93 6.5
< 1 < 1
muscle function, and other findings. Symmetry, periodicity, glottic closure, amplitudes, waveforms, and nonvibrating segments are assessed by using a modification of the format proposed by Hirano." In all cases, prior to strobovideolaryngoscopy diagnoses were recorded based on clinical examination using a laryngeal mirror, and examination of the singing voice when appropriate. Diagnoses based on the strobovideolaryngoscopic examination were compared with preprocedure diagnoses to determine whether strobovideolaryngoscopy was helpful clinically in establishing diagnoses or treatment strategies. We were also interested in determining whether additional clinical and teaching experience since the time of our original report in 1988 had altered the usefulness of strobovideolaryngoscopy in our practice. RESULTS
Three hundred seventy-seven strobovideolaryngoscopic examinations were performed on 352 patients. Forty entities were diagnosed (Table 1). Many patients had more than one diagnosis, although some had their second, third, or fourth diagnosis established at separate office visits during the 12month period. For example, a patient with voice abuse and a varicosity on one visit may have returned with a vocal fold hemorrhage. Table 1 lists each diagnosis every time it was observed during strobovideolaryngoscopy, even if it was present on several examinations in the same patient. Table 1 also lists the number of patients who had each diagnosis at any time during the 12-month period. Seven percent of patients underwent more than one strobovideolaryngoscopic procedure (Table 2). Most of the patients who underwent two or more procedures had vocal fold hemorrhage, vocal nodules, or unrelated problems on different occasions during the 12-month period. In 110 procedures (29%), stroboscopy confirmed the clinical diagnosis and permitted detection of additional diagnoses. In 67 procedures (18%), the clinical diagnosis was found to be incorrect. Thus, during 177 procedures (47 %) strobovideolaryngoscopy provided additional diagnostic information. In 55 cases, the additional findings did not alter medical management. The 122 cases (32.4 % of procedures) in which clinically significant findings were detected only following strobovideolaryngoscopy are summarized in Table 3. These examples include cases of small recurrent carcinoma, cases of delayed resolution of vocal fold hemorrhage, cases of recurrent laryngeal nerve pa-
Sataloff et al, Strobovideolaryngoscopy TABLE 3. CASES IN WHICH STROBOSCOPY MADE SIGNIFICANT DIFFERENCE IN DIAGNOSIS AND/OR TREATMENT
No. of Procedures 1
Lesion Carcinoma Cricothyroid fusion
2
C~
7
Cyst and contact nodule Granuloma Hemorrhage Mass Mucosal tear Myasthenia gravis
4
2 10 12 5 2
~~
Normal larynx with functional dysphonia PolW Recurrent laryngeal nerve paresis Scar Superior laryngeal nerve paresis or paralysis Varicosity VVeb
8 3 2 10 32 16 3 3
resis initially thought to have been paralysis, cases in which vocal fold scar was detected unexpectedly in the presence of other vocal fold disorders such as nodules or cysts, and other conditions. Stroboscopy allowed diagnosis of vocal fold cysts with contralateral reactive nodules in several cases that had been misdiagnosed as bilateral vocal nodules. Accurate stroboscopic diagnosis in these cases altered the treatment plan and decreased the amount of time spent in voice therapy prior to surgical intervention. Stroboscopy is also helpful in documenting normal vocal fold function in cases of psychogenic dysphonia or malingering. Malingering is increasingly common as the number of lawsuits following surgical procedures continues to increase. DISCUSSION
Use of stroboscopic light to evaluate the larynx
727
was first reported in 1895. 3 Since that time, more than 90 articles have recommended the technique, and numerous equipment designs have been proposed, as cited previously.' Recent improvements in laryngeal stroboscopes have provided instrumentation that is practical for clinical use. The technique has proven helpful in evaluating many patients with voice complaints, providing rapid assessment of vibratory function. This permits diagnosis of structural lesions that are often missed altogether without stroboscopy. In comparing our current findings with those reported in our 1988 study, we were somewhat surprised to note a 12 % increase in the percentage of voice visits during which stroboscopy was performed. We believe this is due not to expanded indications for stroboscopy, but rather to the increasing percentage of our patients referred by otolaryngologists for complex medical or legal consultation. In our previous investigation, we reported that stroboscopy provided clinically valuable information in 31.20/0 of the procedures performed. In our present study, there were additional findings in 470/0 of procedures, but important diagnostic changes in only 32.4 %. These remarkably consistent findings confirm the conclusions put forth in our previous report. Strobovideolaryngoscopy provides valuable information that alters diagnosis and/or treatment in about one third of patients for whom the procedure is indicated. It is helpful in confirming clinical impressions in many additional patients. Once skill has been acquired in performing and interpreting strobovideolaryngoscopy, extensive experience does not appear to alter its clinical value. Stroboscopic findings routinely result in changes in diagnosis that alter treatment strategies. We have found the technique invaluable in daily practice and essential for valid, reliable diagnosis of voice disorders.
REFERENCES 1. Sataloff RT, Siegel JR, Carroll LM, Schiebel BR, Darby KS, Rulnick RK. Strobovideolaryngoscopy in professional voice users: results and clinical value. J Voice 1988;1:359-64. 2. Hirano M. Phonosurgery: basic and clinical investigations.
Otologia (Fukuoka) 1975;21:239-442. 3. Oertel MJ. Das Laryngoskopische Untersuchung. Arch Laryngol Rhinol (Bed) 1895;3:1-16.
STROBOVIDEOLARYNGOSCOPY: RESULTS AND CLINICAL VALUE ROBERT JOSEPH
T. SATALOFF, MD
R. SPIEGEL, MD
MARY J. HAWKSHAW,
RN
PHILADELPHIA, PENNSYLVANIA
Strobovideolaryngoscopy is a valuable addition to the diagnostic armamentarium because it allows the otolaryngologist to perform a detailed physical examination of the vibratory margin of the vocal fold. From 1985 through 1989, we performed 1,876 strobovideolaryngoscopy procedures, the majority on professional voice users. Previously, we reported findings on our first 486 strobovideolaryngoscopy procedures. Stroboscopic information influenced diagnosis or treatment in approximately one third. The present study was undertaken to determine whether additional experience had altered the clinical usefulness of the procedure. Diagnoses were noted before and after stroboscopy prospectively for 377 strobovideolaryngoscopy procedures performed during the calendar year 1989. In 530/0 of the procedures, strobovideolaryngoscopy resulted in no change in diagnosis. In 29 %, preprocedure impressions were confirmed and additional diagnoses were made. In 180/0, preprocedure diagnoses were found to be incorrect. The procedure has proven very helpful in caring for voice patients, modifying diagnoses in 47 0/0, and confirming uncertain diagnoses in many of the other patients studied.
KEY WORDS - stroboscopy, strobovideolaryngoscopy, voice.
Complex motion of the vibratory margin of the vocal folds is essential for normal voice. Because the vocal folds open and close between about 60 and 1,500 times per second depending upon the pitch of phonation, valid, reliable physical examination of the vibratory margin cannot be accomplished by using continuous light and a laryngeal mirror. Highspeed photography permits slow-motion evaluation of vocal fold vibration, but it is cumbersome. It also permits evaluation of only relatively short samples of phonation. High-speed video is not widely available and shares many disadvantages with high-speed photography. Strobovideolaryngoscopy is currently the most convenient technique permitting the otolaryngologist to perform a detailed assessment of the vibratory margin of the vocal fold. From 1985 through 1989, we performed 1,876 strobovideolaryngoscopy procedures. All strobovideolaryngoscopic examinations were performed by an otolaryngologist, usually with the assistance of a nurse, speechlanguage pathologist, and/or singing voice specialist. The majority were on professional voice users. Previously, we reported findings on our first 486 strobovideolaryngoscopy procedures. 1 Stroboscopic information influenced diagnosis or treatment in approximately one third of cases. The present study was undertaken to determine whether additional experience had altered the clinical usefulness of the procedure.
ing which strobovideolaryngoscopy was performed comprised approximately 32 % of voice patient visits, and stroboscopy was performed on 60 % of the patients seen during that period. All patients were selected because of the presence or suspicion of a structural or neurologic abnormality, or to prove the absence of such a lesion. Of the 352 patients who underwent strobovideolaryngoscopy, the majority were professional voice users, and 129 of these were singers. The other patients also sought medical attention specifically for voice complaints. All stroboscopic examinations were performed with a Bruel and Kjaer rhinolarynx stroboscope type 4914, with the patient seated. An Olympus flexible nasolaryngoscope and a magnifying telescope were used in virtually all cases. Initially, examinations were performed while looking directly into the laryngoscope before connecting it to the video system. In some cases, the laryngoscope was also connected to a Zeiss operating microscope using a custommade adaptor, before strobovideolaryngoscopy. This technique provides high-quality magnification, which is especially helpful in those few patients who will not tolerate the laryngeal telescope. The flexible laryngoscope permits observation of vocal fold function under continuous and stroboscopic light during a variety of phonatory tasks, with relatively undistorted vocal tract anatomy. The magnification and high optical quality provided by a rigid laryngeal telescope are invaluable and obviate the need for magnification with an operating microscope in most cases. However, they permit vocal fold evaluation only during relatively awkward vocal tract positions and tasks. Simultaneous synchronized electroglottography was also performed, and the electroglottographic waveform
MATERIALS AND METHODS
Three hundred seventy-seven strobovideolaryngoscopy procedures were performed on 352 patients between January 1, 1989, and December 31, 1989. During that period, we saw 583 voice patients for a total of 1,180 voice-related visits. The 377 visits dur-
From the Department of Otolaryngology, Thomas Jefferson University (Sataloff, Spiegel), and the American Institute for Voice and Ear Research (Hawkshaw), Philadelphia, Pennsylvania. Presented at the meeting of the American Laryngological Association, Waikoloa, Hawaii, May 4-5, 1991. REPRINTS - Robert T. Sataloff, MD, 1721 Pine St, Philadelphia, PA 19103.
725
726
Satalojj et al, Strobovideolaryngoscopy
TABLE 1. FORTY ENTITIES OBSERVED DURING 377 STROBOVIDEOLARYNGOSCOPIC PROCEDURES Diagnosis Arytenoid dislocation Cancer Cricothyroid fusion Cysts Dysarthria Dysphonia Dysphonia plica ventricularis Functional dysphonia Th~~~~
Granuloma Hemorrhage Histoplasmosis Hoarseness Laryngeal spasm Laryngitis Leukoplakia Lymphoid hyperplasia Mass Mucosal tear Myasthenia gravis Nerve paralysis or paresis Nodules Nmmal Parkinson's disease ~yp
Presbyphonia Reflux laryngitis Reinke's edema Respiratory dysfunction Sarcoidosis Scar with stiffness Subglottic stenosis Temporomandibular joint syndrome Tonsillitis Trauma
No. of Procedures 2
No. of Patients 2
TABLE 2. NUMBER OF PROCEDURES EXPERIENCED BY INDIVIDUAL PATIENTS No. of Procedures per Patient 1
Patients No. %
4
3
2
326 23
1 10 1
1 8 1
3 4
1 2
50
45
8
5
9
9
1
1
3 30 1 2 7 21 2 2 87 6 3
3 26
66
1 2 2 18 1 1 86 6 3 59
34
32
7
5
1 6 12 186 10 1 1 59 1
1 4 10 165 4 1 1
1
1
32
1
1
1
4
3
~~
1
1
Upper respiratory tract infection Varicosity Voice abuse" VVeb
1
1
11 133 5
10 126 5
"Includes hypofunctional and hyperfunctional voice abuse, muscular tension dysphonia, and improper singing or speaking technique.
was superimposed on the laryngeal image. Electroglottography provides an assessment of each vibratory event. This is a valuable adjunct because the stroboscope only simulates slow motion by imaging fragments of successive vibratory cycles. All examinations were recorded on videotape and stored. Duplicates were made routinely for the referring physician, speech-language pathologist, singing teacher, or patient. Black and white and color video printers are also connected to the system for documentation and patient education. Our videostroboscopy protocol involves speaking at various frequencies and intensities, pitch sliding, sniffing, whistling, rapid repetition of syllables, singing, sustained vowel phonation, and other selected tasks. Observations are recorded about voice quality, laryngeal color, vocal fold motion, vibratory margin motion, structural abnormalities, supraglottic
93 6.5
< 1 < 1
muscle function, and other findings. Symmetry, periodicity, glottic closure, amplitudes, waveforms, and nonvibrating segments are assessed by using a modification of the format proposed by Hirano." In all cases, prior to strobovideolaryngoscopy diagnoses were recorded based on clinical examination using a laryngeal mirror, and examination of the singing voice when appropriate. Diagnoses based on the strobovideolaryngoscopic examination were compared with preprocedure diagnoses to determine whether strobovideolaryngoscopy was helpful clinically in establishing diagnoses or treatment strategies. We were also interested in determining whether additional clinical and teaching experience since the time of our original report in 1988 had altered the usefulness of strobovideolaryngoscopy in our practice. RESULTS
Three hundred seventy-seven strobovideolaryngoscopic examinations were performed on 352 patients. Forty entities were diagnosed (Table 1). Many patients had more than one diagnosis, although some had their second, third, or fourth diagnosis established at separate office visits during the 12month period. For example, a patient with voice abuse and a varicosity on one visit may have returned with a vocal fold hemorrhage. Table 1 lists each diagnosis every time it was observed during strobovideolaryngoscopy, even if it was present on several examinations in the same patient. Table 1 also lists the number of patients who had each diagnosis at any time during the 12-month period. Seven percent of patients underwent more than one strobovideolaryngoscopic procedure (Table 2). Most of the patients who underwent two or more procedures had vocal fold hemorrhage, vocal nodules, or unrelated problems on different occasions during the 12-month period. In 110 procedures (29%), stroboscopy confirmed the clinical diagnosis and permitted detection of additional diagnoses. In 67 procedures (18%), the clinical diagnosis was found to be incorrect. Thus, during 177 procedures (47 %) strobovideolaryngoscopy provided additional diagnostic information. In 55 cases, the additional findings did not alter medical management. The 122 cases (32.4 % of procedures) in which clinically significant findings were detected only following strobovideolaryngoscopy are summarized in Table 3. These examples include cases of small recurrent carcinoma, cases of delayed resolution of vocal fold hemorrhage, cases of recurrent laryngeal nerve pa-
Sataloff et al, Strobovideolaryngoscopy TABLE 3. CASES IN WHICH STROBOSCOPY MADE SIGNIFICANT DIFFERENCE IN DIAGNOSIS AND/OR TREATMENT
No. of Procedures 1
Lesion Carcinoma Cricothyroid fusion
2
C~
7
Cyst and contact nodule Granuloma Hemorrhage Mass Mucosal tear Myasthenia gravis
4
2 10 12 5 2
~~
Normal larynx with functional dysphonia PolW Recurrent laryngeal nerve paresis Scar Superior laryngeal nerve paresis or paralysis Varicosity VVeb
8 3 2 10 32 16 3 3
resis initially thought to have been paralysis, cases in which vocal fold scar was detected unexpectedly in the presence of other vocal fold disorders such as nodules or cysts, and other conditions. Stroboscopy allowed diagnosis of vocal fold cysts with contralateral reactive nodules in several cases that had been misdiagnosed as bilateral vocal nodules. Accurate stroboscopic diagnosis in these cases altered the treatment plan and decreased the amount of time spent in voice therapy prior to surgical intervention. Stroboscopy is also helpful in documenting normal vocal fold function in cases of psychogenic dysphonia or malingering. Malingering is increasingly common as the number of lawsuits following surgical procedures continues to increase. DISCUSSION
Use of stroboscopic light to evaluate the larynx
727
was first reported in 1895. 3 Since that time, more than 90 articles have recommended the technique, and numerous equipment designs have been proposed, as cited previously.' Recent improvements in laryngeal stroboscopes have provided instrumentation that is practical for clinical use. The technique has proven helpful in evaluating many patients with voice complaints, providing rapid assessment of vibratory function. This permits diagnosis of structural lesions that are often missed altogether without stroboscopy. In comparing our current findings with those reported in our 1988 study, we were somewhat surprised to note a 12 % increase in the percentage of voice visits during which stroboscopy was performed. We believe this is due not to expanded indications for stroboscopy, but rather to the increasing percentage of our patients referred by otolaryngologists for complex medical or legal consultation. In our previous investigation, we reported that stroboscopy provided clinically valuable information in 31.20/0 of the procedures performed. In our present study, there were additional findings in 470/0 of procedures, but important diagnostic changes in only 32.4 %. These remarkably consistent findings confirm the conclusions put forth in our previous report. Strobovideolaryngoscopy provides valuable information that alters diagnosis and/or treatment in about one third of patients for whom the procedure is indicated. It is helpful in confirming clinical impressions in many additional patients. Once skill has been acquired in performing and interpreting strobovideolaryngoscopy, extensive experience does not appear to alter its clinical value. Stroboscopic findings routinely result in changes in diagnosis that alter treatment strategies. We have found the technique invaluable in daily practice and essential for valid, reliable diagnosis of voice disorders.
REFERENCES 1. Sataloff RT, Siegel JR, Carroll LM, Schiebel BR, Darby KS, Rulnick RK. Strobovideolaryngoscopy in professional voice users: results and clinical value. J Voice 1988;1:359-64. 2. Hirano M. Phonosurgery: basic and clinical investigations.
Otologia (Fukuoka) 1975;21:239-442. 3. Oertel MJ. Das Laryngoskopische Untersuchung. Arch Laryngol Rhinol (Bed) 1895;3:1-16.
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