Validity and reliability of grade scoring in the diagnosis of exercise-induced laryngeal obstruction

Abstract

The current gold-standard method for diagnosing exercise-induced laryngeal obstruction (EILO) is continuous laryngoscopy during exercise (CLE), with severity classified by a visual grade scoring system. We evaluated the precision of this approach, by evaluating test–retest reliability of CLE and both inter- and intra-rater variability.In this prospective case–control study, subjects completed four consecutive treadmill CLE tests under identical conditions. Laryngoscopic video recordings were anonymised and graded by three expert raters. 2 months following initial scoring, videos were re-randomised and rating repeated to assess intra-rater agreement.20 subjects (16 cases and four controls) completed four CLE tests. The time to exhaustion increased by 30 s (95% CI 0.02–57.8, p<0.05) in the second CLE compared with the first test, but remained identical in the subsequent tests. Only one-third of subjects retained their initial diagnosis in the subsequent three tests. Inter-rater agreement on grade scores (weighted Cohen's ϰ) was 0.16–0.45, while intra-rater agreement ranged from 0.30 to 0.67.The CLE test is key in the diagnostic assessment of patients with EILO. However, the widely adopted visual grade scoring system does not appear to be a robust means for reliably classifying severity of EILO.

Surgical intervention for exercise‐induced laryngeal obstruction: A UK perspective

“…There is significant interrater and intrarater variability using this approach, so although the preoperative severity was finalized through multitester agreement during the MDT, there is still the possibility of interrater and intrarater variability if the videos were to be looked at again. 34 More robust and objective quantification systems of any propensity of laryngeal closure are thus needed to ensure that improvements postsurgery can be more accurately classified and quantified. Likewise, outcome tools to quantify the subjective benefit of any intervention in EILO are currently an important unmet need.…”

Exercise-induced laryngeal obstruction in athletes treated with inspiratory muscle training

“…CLE testing has been successfully applied in numerous recent studies in this field of respiratory medicine 1 2 4–6 11 17 27–35. Studies addressing the validity and reliability of the CLE scoring system have reached somewhat variable conclusions 17 36 37. It nevertheless seems reasonable to conclude that experience is a factor that influences these issues.…”

Exercise-induced laryngeal obstruction in athletes: Contributory factors and treatment implications

“…Laryngoscopic visualization of inappropriate glottic or supraglottic movement causing the narrowing is considered essential for making the EILO diagnosis. A continuous laryngoscopy exercise (CLE) test providing key information on the degree of obstruction has been developed for this purpose (Heimdal et al, 2006;Maat et al, 2009), although the test does not appear to be a robust means for reliably classifying the severity of EILO (Walsted, Hull, Hvedstrup, Maat, & Backer, 2017). Unfortunately, the clinical presentation of EILO is often misdiagnosed and patients receive medical treatment for asthma, exercise-induced bronchoconstriction or exercise-induced asthma, despite lack of evidence to support the diagnoses and continued lack of response to such treatment (McFadden Jr & Zawadski, 1996;McQuaid, Spieth, & Spirito, 1997;Newman, Mason, & Schmaling, 1995;Nielsen et al, 2013;Thomas, Geddes, & Barnes, 1999).…”