Recorded Flexible Nasolaryngoscopy for Neonatal Vocal Cord Assessment in a Prospective Cohort

Abstract

Objective: Assessing vocal cord mobility by flexible nasolaryngoscopy (FNL) can be difficult in neonates. To date, prospective studies evaluating the incidence and diagnostic accuracy of vocal cord paralysis (VCP) after surgical patent ductus arteriosus (PDA) ligation are limited. It is unknown whether video FNL improves diagnosis in this population. This study compared video recordings with bedside evaluation for diagnosis of VCP and determined inter-rater reliability of the diagnosis of VCP in preterm infants after PDA ligation. Methods: Prospective cohort of preterm neonates undergoing bedside FNL within two weeks of extubation following PDA ligation. In a subset, FNL was recorded. Two pediatric otolaryngologists, blinded to the initial diagnosis, reviewed the FNL video recordings. Results: Eighty infants were enrolled and 37 with a recorded FNL were included in the cohort. Average gestational age at birth was 25.2 weeks (SD: 1.2) and postmenstrual age at FNL was 37.0 weeks (SD: 4.5), which was 9.5 days (SD: 14.7) after extubation following PDA repair. There were 6 diagnosed with left VCP (16.2%; 95% CI: 4.3-28.1%) at bedside, and 9 diagnosed by video review (24.3%; 95% CI: 10.5-38.1%) ( P = .56). Videos confirmed all 6 VCP diagnosed initially, but also identified 3 additional cases. Though imperfect, reviewing FNL by video showed substantial reliability (kappa = .75), with 91.9% agreement. Conclusion: Video recorded FNL most often confirms a bedside diagnosis of VCP, but may also identify discrepancies. Physicians should consider the limitations of diagnosis especially when infants persist with symptoms such as weak voice or signs of postoperative aspiration. Level of Evidence 2b

The Best Modality to Assess Vocal Fold Mobility in Children: Flexible Fiberoptic Laryngoscopy or Ultrasound?

“…There was fair reliability between pediatric otolaryngologists viewing the videos (kappa = 0.75) with 91% agreement. 1 Liu et al evaluated 20 infants and assessed inter-rater reliability of video-recorded FFL and found substantial agreement on immobility versus normal mobility (kappa = 0.67), but only moderate reliability on the degree of immobility (kappa = 0.49). 2 Historically, US was considered limited by operatordependent image quality and interpretation.…”

“…Initial FFL identified six patients with VFI and an additional three patients were found to have immobility on review of the video (initially thought to have normal mobility). There was fair reliability between pediatric otolaryngologists viewing the videos (kappa = 0.75) with 91% agreement 1 . Liu et al evaluated 20 infants and assessed inter‐rater reliability of video‐recorded FFL and found substantial agreement on immobility versus normal mobility (kappa = 0.67), but only moderate reliability on the degree of immobility (kappa = 0.49) 2 …”

“…The gold standard in the evaluation of VFI in children is awake flexible fiberoptic laryngoscopy (FFL). Over the past decade, ultrasound (US) has gained increasing attention as a modality for assessing vocal fold mobility in children, especially as a screening exam prior to FFL 1,2 …”

“…Over the past decade, ultrasound (US) has gained increasing attention as a modality for assessing vocal fold mobility in children, especially as a screening exam prior to FFL. 1,2…”

Ultrasound of the vocal cords in infants

“…In small children, while the interobserver agreement between normal versus abnormal vocal cord movement on flexible nasopharyngolaryngoscopy is substantial, the agreement between the degree of movement of the vocal cord (paralysis vs. paresis) is only moderate [30]. A recent publication suggested that video recording flexible nasopharyngolaryngoscopy exams improves diagnostic accuracy of vocal cord paralysis in neonates [31].…”