VALUE OF LARYNGEAL ULTRASOUND IN COMPARISON TO VOCAL CORD VIDEO STROPOSCOPY IN DIAGNOSIS OF VARIOUS LARYNGEAL LESIONS

VALUE OF LARYNGEAL ULTRASOUND IN COMPARISON TO VOCAL CORD VIDEO STROPOSCOPY  IN DIAGNOSIS OF VARIOUS LARYNGEAL LESIONS

By

Hala Maghraby and Hala Abd El-Haseeb*

Departments of Radiology and Otolaryngology*

Faculty of Medicine, Al Azhar University, Cairo, Egypt

ABSTRACT

Background: Video stroposcopy is useful in diagnosis of various laryngeal lesion.  Laryngeal ultrasound is also used as a beneficial tool in this diagnosis. Objectives: The main aim of this study was to evaluate the value of laryngeal ultrasound in comparison to vocal cord stroposcopy in diagnosis of different laryngeal lesions. Patients and Methods: This study which was carried out between August 2014 and April 2015 in Radio diagnosis and Otorhinolaryngology Departments, Al-Zahraa University Hospital, Egypt. The study included groups of thirty patients who had complaints related to the larynx as hoarseness of voice, stridor, chronic cough, chocking attacks or neck swelling. These patients were referred from the ENT outpatient clinic. All the patients of the study group were subjected to both laryngeal ultrasound and vocal cord stroposcopy. Results: Twelve patients (40%) were normal, two patients  (6.6%) had vocal fold palsy,  four patients (13,3 %) had vocal fold nodules, three (10%) had vocal fold polyp, two (6.6%) had vocal fold hypertrophy, two (6.6%) had intrarytenoid edema, one (3.3%) had anterior commissure mass enchroaching upon the right vocal cord, one  (3.3%)  had submandibular swelling and three (10%) had multinodular goitre. Conclusion: Laryngeal ultrasound can be used in diagnosis in different  vocal cord lesions. It can be used as a complementary tool to vocal cord stroposcopy in diagnosis of vocal cord lesions.

INTRODUCTION

     Different methods have been used successfully in diagnosis of different vocal cord lesions (Singh et al., 2010 and   Shalaby et al., 2013). Fibro-optic laryngoscope was used in otolaryngology outpatient clinic for laryngeal evaluation. The image of laryngoscope is larger, brighter and clearer which allows earlier diagnosis (Eller et al., 2008 and Matta et al., 2015). However, not all patients can tolerate the rigid laryngoscope especially those who are suffering from stridor, sensitive gag reflex, patients with limit of jaw mobility or neck mobility as well as infants and children (Hartnick and  Zeitels, 2005).  Ultrasound became a very important widely used diagnostic tool for the head and neck diseases. However it was rarely used in the diagnosis of laryngeal diseases (Wolf et al., 2005 and Kundra et al., 2011). High-frequency ultrasound in the last years became an effective diagnostic tool with small, flexible ultrasound transducers (Wendy, 2007) and (Gomaa et al., 2013).

     The present work was to evaluate the value of laryngeal ultrasound in comparison to vocal cord storoposcopy in diagnosis of different laryngeal lesions.

PATIENTSAND METHODS

     The study was approved by the clinical research committee of the radio diagnosis and otolaryngology departments, Faculty pf Medicine, Al Azhar University, Cairo, Egypt. The study started in July 2014 and ended in March 2015. All the patients of the study were consented and submitted to discussion bout the methods of examination of the laryrx by the two ways of the techniques. All the patients were agreed to do both methods of diagnosis.

     The study group included thirty patients (18 females and 12 males) who had hoarseness of voice, chronic cough, chocking attacks, stridor, or neck swelling.  The mean age was 47.5 ± 8.8 years (35-60 years). These patients were referred from the ENT outpatient clinic at Al-Zahra’a University Hospital. All patients were subjected to full history and examination using the high-resolution laryngeal ultrasound technique, which was carried out using a small linear probe of 7–12 MHz frequency using general electric volusion -730- Expert machine, and Logic 6 machine with a linear probe for the visualization of the laryngeal structures. The vocal cords were examined in two phases: Quite breathing for assessment of vocal cord lesions, and during phonation (long E) to assess vocal cord mobility. All the patients were also subjected to vocal cord stroposcopy.

      Thus, the video image of one cycle is obtained from different portions of several cycles. The stroposcopic flashes can be emitted in one of two ways:

● Synchronization, illumination: at the same frequency of phonation.

● Asynchronization illumination at a slight variation of frequency.

     Vibratory pattern was detected regarding the glottic wave (mucosal wave), amplitude of vibration, symmetry of bilateral movement, periodicity, Glottic closure, non vibrating portions (fixation) and phase closure.

Statistical analysis: Data were analyzed using statistical program for social science (SPSS) version 18.0. Qualitative data were expressed as frequency and percentage.

The following tests were done:

● Chi-square (X²) test of significance was used in order to compare proportions between two qualitative parameters.

● Receiver operating characteristic (ROC curve) analysis was used to find out the overall productivity of parameter in and to find:

● Sensitivity: Probability that a test result was positive when the disease was present (true positive rate, expressed as a percentage).

● Specificity: Probability that a test result was negative when the disease was not present (true negative rate, expressed as percentage).

● Probability (P-value) P-value <0.05 was considered significant.

RESULTS

    Demographic data distribution of the study group as regards to age and sex were showed the percentage of male 40% to female 60% of the groups. The age ranged from 35-60 years with mean age ± SD 47.5 ± 8.8 years (Table 1).

Table (1): Demographic Data distribution of the study group as regards to the age and sex.

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     The study included thirty patients suffering from laryngeal symptoms. Twelve patients (40%) were normal with no evidence of any abnormality either by laryngeal ultrasound or by vocal cord stroposcopy (Fig. 1). Two patients (6.6 %) have limited mobility and diagnosis was confirmed by vocal cord stroposcopy as a vocal cord paralysis. Four patients (13.3%) had a vocal cord nodule that was diagnosed by ultrasound, and confirmed correctly by a vocal cord stroposcopy (Fig, 2 a,b). Three patients (10%) had a vocal cord polyps; diagnosed by laryngeal ultrasound and confirmed by a vocal cord stroposcopy. Two patients (6.6%) had interarytenoid edema, but the lesion could not be diagnosed by ultrasonography, and the  two cases had recurrent attacks of chocking and  misdiagnosed as they had gastroesophageal reflux disease. They were correctly diagnosed by vocal cord stroposcopy, (Fig. 3 a,b). Two patients (6.6%) had hypertrophy of both  vocal cords and  complained from recurrent attacks of hoarseness of voice and chocking attacks. They were diagnosed by laryngeal ultrasonography and confirmed by vocal cord stroposcopy.  One patient (3.3%) had an anterior commissure mass enchroaching upon the right vocal cord. The condition was diagnosed by laryngeal ultrasonography and confirmed by vocal cord stroposcopy, (Fig. 4 ,a,b). One patient (3.3%) had bilateral submandi-bular swelling. By laryngeal ultrasound, both submandibular glands were found enlarged with heterogenous echopattern and surrounded by multiple cervical and submandibular lymphadenopathy. The condition was diagnosed as bilateral submandibular sialoadenitis and received medical treatment. After three weeks follow up, the study revealed the relief of the condition, and the patient became normal. Three patients (10%) had multinodular goiter and diagnosed well by laryngeal ultrasonography only, (Fig. 5).

     The level of senstivity, specificityand accuracy ogeal lesions by both methods: Normal  (100.0%, 100.0% and 100.0%), Vocal cord paralysis (0.0%, 100.0% and 50.0%), Vocal cord nodule (100.0%, 100.0% and 100.0%), vocal cord polyp (100.0%, 100.0% and 100.0%), intera-rytenoid edema (0.0%, 100.0% and 50.0%), hypertrophy of both vocal cords (100.0%, 100.0% and 100.0%), Anterior commissure mass (100.0%, 100.0% and 100.0%), bilateral submandibular swelling (100.0%, 0.0% and 50.0%), multinodular goiter (100.0%, 0.0% and 50.0%) respectively (Table 2).

Table (2): Diagnostic Performance of various laryngeal lesions by laryngeal ultrasound and vocal cord video- stroposcopy as regards to sensitivity, specificity and accuracy.

Also, in this study, comparison between laryngeal ultrasound and vocal cord video-stroposcopy as regards to various laryngeal pathologies showed a difference between both methods asregard to cord paralysis, interarytenoid edema, bilateral submandibular swelling and multinodular goiter but non significant. The rest have equal results (table 3).

Table (3):  Comparison between laryngeal ultrasound and vocal cord video  stroposcopy as regard to various laryngeal lesions.

Figure (3b): laryngeal ultrasonography of the same patient which is completely normal.

Figure (4 a,b): Small mass lesion seen at the anterior commissure enchroaching upon the right vocal fold.

Figure (5): Laryngeal ultrasound revealing multinodular goiter.

DISCUSSION

      For several decades, vocal cord evaluation was performed using the indirect mirror examination. More recently, the Otolaryngologists use of the fiberoptic laryngoscope for routine evaluation of the larynx. However, this technique requires a cooperative patient as well as application of topical anesthetic and decongestant (Dedecjus et al., 2010). Ultrasound imaging has become a very powerful tool for diagnostic radiology, especially in scanning of the head and neck (Singh M et al., 2010 and Shalaby et al., 2013).

     Jadcherla SR et al. (2006), imaged the complete visualization of adduction and abduction of the vocal cords by vocal cord  stroposcopy. High- resolution laryngeal ultrasonography at frequencies ranging from 10 to 30 MHz was demonstrated to be useful in the diagnosis of various lesions of the vocal folds (Huang et al., 2007). Laryngeal ultrasound has many advantages including its simplicity, safety, non-invasive, non-expensive, painless, and anesthesia is not necessary  (Sirikci A et al., 2007 and Nasr et al., 2013).

     In the present study, comparison between laryngeal ultrasound and vocal cord video-stroposcopy showed a difference between laryngeal ultrasound and vocal cord stroposcopy in vocal cord paralysis, inter arytenoids edema, bilateral submandibular swelling and multi-nodular goiter. The rest of the other  laryngeal lesions have equal results between both techniques. These results agreed with Zajkowski (2007) who stated that ultrasound considered the first imaging in the salivary g;and diseases, and as valuable adjunct in some laryngeal pathologies. This result was also in agreement with Gomaa et al. (2013).

     The accuracy of various laryngeal lesions in this study with video-stroposcopy amd laryngeal ultrasound were totally have the same results except in vocal cord paralysis, interarytenoid  edema, bilateral submandibular swelling and multinoduar goiter. This agreed with Khalil  et al. (2010) who found that the free margin of the vocal folds could not be well delineated due to the air-soft tissues interface. Also, complete thyroid cartilage calcification causing the visualization of the laryngeal space is unclear as complete calcification of the thyroid cartilage created an acoustic shadow which made it hard to analyze the larynx (Khalilet al. 2010; Hu et al. 2011 and  Matta et al. 2015). 

    In the present work, the normal anatomy of the vocal folds was well demarcated, whereas the posterior part of the free margins were not clearly identified. This is in agreement with Nasr et al. (2013) and Gomaa et al. (2013).

     Also, in this work, the thyroid lamina, anterior commissure and vocal process of the arytenoids cartilage were clearly demarcated during both phonation and normal breathing. This is consistent with results of Nasr et al. (2013). The vocal cord movement is clearly visible in all cases of this study except in two patients who presented with vocal cord paralysis and their thyroid cartilages were calcified. This was in agreement with study of Nasr et al. (2013).

     In this study, it was found that vocal cord nodules were detected in four patients (13.3%) and vocal cord polyps in three patients (10%). These two lesions were detected in 100% of patients on performing laryngeal ultrasound as well as vocal cord video-stroposcopy (Table 2 and 3). It is in agreement with the findings of Khalil el al. (2010).

     By comparison of the findings of laryngeal ultrasonography and vocal cord video-stroposcopy in this study, it had been found that both modalities were comparable with a great extent. Moreover, the laryngeal ultrasound was more valuable in detecting all various laryngeal lesions except in vocal cord paralysis and interarytenoid edema, but the vocal cord video-stropscopy results were better in interarytenoid edema and vocal cord thickening and edema that was detected in four patients (6.7% for each lesion respectively). The accuracy represented 50% and 100% as regard to these two lesions which were performed by both modalities. These results were in agreement with Khalil et al. (2010) who concluded that laryngeal ultrasound had the same diagnostic ability as vocal cord video-stroposcopy in the assessment of vocal cord mobility. The results of our study were also in agreement with the results of HU et al. (2011) who decided that laryngeal ultrasonography was considered a non-invasive complementary technique in detecting some types of laryngeal lesions.

     Ultrasound is considered as the first imaging tool in diagnosis of soft tissues of the head and neck and some laryngeal pathologies. Real time ultrasound examination allows for dynamic assessment of lesions. (Zajkowski and Biatek, 2007). Also, the ultrasound evaluate the mobility of the vocal cord that can be assessed easily by scanning in the midline transversely (Loveday, 2003 and Enaba et al., 2012). Our study agreed with Khalil et al.  (2010); Amis et al. (2012) and Mohamed et al. (2015) that concluded that the laryngeal ultrasound has the same diagnostic ability as the video-stroposcopy in the assessment of the vocal cord mobility.

     Khalil et al. (2010) and Wang et al. (2012) studied that the ultrasound can detect vocal cord modules and polyps. The intra-arytenoid edema could not be detected as the arytenoid and intera-rytenoid area could not be identified by laryngeal ultrasound. However, the vocal cord video-stroposcopy was more useful. This was in agreement with Khalil et al. (2010) who reported that the interaryte-noid edema could not be detected as the arytenoids, and interarytenoid area could not be seen by laryngeal ultrasound. No cases of ulceration was found in our study (Shao et al. 2002 and Schade et al. 2006).

     Today, vocal cord video-stroposcopy is the clinical gold standard for assessment of phonatory and valvular functions of the glottis (Matta et al., 2015). However, it may suffer from some limitations imposed by a sensitive gag reflex or neck and jaw rigidity (Hartnick and Zeitels, 2005).

CONCLUSION

     High-resolution laryngeal ultrasound can be used in diagnosis of different vocal cord lesions as a complementary tool to video stroposcopy for diagnosis of various lesions of vocal cords. However, it cannot be used as the first tool for diagnosis before special experience has to be gained prior to it.

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