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Year : 2013  |  Volume : 26  |  Issue : 2  |  Page : 170-176

Ultrasonography diagnostic validity in structural and functional laryngeal disorders

1 Department of Radiology, Mansoura New General Hospital, Mansoura, Egypt
2 Department of Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission03-Mar-2013
Date of Acceptance05-Jun-2013
Date of Web Publication31-Jan-2014

Correspondence Address:
Hazem A.A. Shalaby
84 Ahmed Abdulazeem Street, Mehallet Alborg, Al-Mahalla Al-Kobra, Gharbia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-2098.126158

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The aim of the study was to assess the role of ultrasound in detecting and characterizing laryngeal anatomy with a special focus on vocal cords and study of some laryngeal disorders and their possible ultrasonographic appearance.
Laryngeal examination with rigid endoscopy has the advantages of producing large, bright images. Unfortunately, patients with a sensitive gag reflex, patients with limited jaw or neck mobility, or those with stridor may not tolerate laryngeal endoscopic examination. It is also difficult in most infants and children. Thus, high-resolution (frequency) laryngeal ultrasonography may provide an alternative diagnostic tool.
Patients and methods
The study group included 50 patients who had complaints related to the larynx such as hoarseness of voice, chronic cough, chocking attacks, stridor, or neck swelling. These patients were referred from the ENT outpatient clinic.
In the present study, of the 50 patients with laryngeal complaints, 10 patients (20%) were normal, 10 (20%) had vocal fold palsy, 10 (20%) had laryngeal tumor, four (8%) had vocal fold ulcer, four (8%) had vocal fold nodules, three (6%) had vocal fold polyp, three (6%) had vocal fold cyst, two (10%) had vocal fold dysfunction, two (10%) had interarytenoid edema, and two (10%) had laryngocele.
High-resolution laryngeal ultrasound can be used for assessment of vocal fold lesions, tumors, and mobility. Because of its real-time ability and noninvasive nature, ultrasonography is considered an effective diagnostic tool for the proper assessment of the vocal fold mobility rather than other diagnostic modalities, but is less effective in vocal cord ulcers and small lesions because of a limitation of the air-mucosa interface

Keywords: Laryngeal sonography, laryngeal ultrasound, vocal folds ultrasonography

How to cite this article:
Shalaby HA, Maaly MA, Abdella TF. Ultrasonography diagnostic validity in structural and functional laryngeal disorders. Menoufia Med J 2013;26:170-6

How to cite this URL:
Shalaby HA, Maaly MA, Abdella TF. Ultrasonography diagnostic validity in structural and functional laryngeal disorders. Menoufia Med J [serial online] 2013 [cited 2020 Mar 30];26:170-6. Available from: http://www.mmj.eg.net/text.asp?2013/26/2/170/126158

  Introduction Top

Manuel Garcia first used a dental mirror to visualize vocal cords in 1854 [1] . Then, different methods were used successfully for the diagnosis and treatment of many laryngeal diseases [2] . A rigid endoscope was used in otolaryngology outpatient departments for laryngeal evaluation with the advantages that the image is larger, brighter, and clearer, allowing earlier diagnosis [3],[4] .

Unfortunately, not all patients can tolerate the rigid laryngoscope [5] .

In recent decades, computed tomography (CT) and MRI have been the primary imaging modalities of the larynx, but recently, ultrasound imaging has become a very powerful tool for diagnostic radiology, especially in scanning the head and neck regions [6] .

  Patients and methods Top

The study group included 50 patients who had complaints related to the larynx such as hoarseness of voice, chronic cough, chocking attacks, stridor, or neck swelling. These patients were referred from the ENT outpatient clinic (Mansoura New General Hospital) during the time period from November 2011 to April 2013. All patients were subjected to full history and examination using the high-resolution laryngeal ultrasound (HRLU) technique, which was carried out using a small linear probe of 6-13 MHz frequency (Philips EnVisor HD version C.1.4.).

  Results Top

The study included 50 patients (29 males and 21 females), age range 7-78 years, who presented clinically with different complaints related to the larynx.

Patients were referred to the radiology department from the ENT department for a noninvasive examination of the larynx with ultrasonography using the HRLU technique.

Our results were correlated with clinical follow-up of cases, surgical findings, laryngoscope, and histopathological reports.

Clinically, the main complaint in our patients was hoarseness of voice [Table 1].
Table 1: Different clinical presentation of the patients included in this study

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In the present study, of the 50 patients with laryngeal complaints, 10 patients (20%) were normal, with no evidence of any abnormality either by ultrasound or by laryngoscopy [Table 2].
Table 2: Different laryngeal lesions included in this study

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In the present study, 10 patients with laryngeal tumors of the 50 patients included in this study (20%) were examined by ultrasonography, and tumor involvements of the following subsites were evaluated: anterior commissure, pre-epiglottic space, paraglottic space, subglottic region, laryngeal cartilage, and extralaryngeal tissues [Table 3]. On ultrasonography, the tumor appeared hypoechoic or showed a heterogeneous echo pattern.

These imaging interpretations were compared with other CT images, biopsies, and the postoperative histopathological classification. The evaluation of vocal cord mobility was compared with the findings at laryngoscopy.
Table 3: Results of ultrasonography and subsite involvement detection in 10 patients with laryngeal carcinoma

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All patients with laryngeal tumors were biopsied histopathologically, and the results showed squamous cell carcinoma (100%). Ultrasonography identified the majority of the laryngeal carcinomas; only one T2 stage tumor of an aryepiglottic fold was missed. The microscopic involvement of thyroid cartilage with a T3 stage tumor was not detected on both ultrasonography and CT [Table 4].
Table 4: Tumor location and T stage at histopathology, ultrasonography, computed tomography, and laryngoscope in 10 patients with laryngeal carcinoma

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Ten of 50 patients included in this study (20%) were correctly diagnosed by ultrasound as having vocal cord palsy by observing limitation of vocal cord movement on real-time ultrasound B-mode (nine cases were unilateral and one case was bilateral) and confirmed by laryngoscope examination.

Four of 50 patients (8%) had vocal cord ulceration that was not diagnosed by ultrasound but correctly diagnosed by a laryngoscope.

Four of 50 patients (8%) had a vocal cord nodule that could not be diagnosed by ultrasound but can be correctly diagnosed by a laryngoscope.

Three of 50 patients (6%) had a vocal cord polyp; one of them was diagnosed by ultrasound and confirmed by a laryngoscope, but the other two cases were missed by ultrasound but correctly diagnosed by a laryngoscope.

Three of 50 patients (6%) had a vocal cord cyst; two of them were diagnosed by ultrasound and confirmed by a laryngoscope, but the remaining case was missed by ultrasound as it was less than 3 mm but correctly diagnosed by a laryngoscope.

Two of 50 patients (4%) had interarytenoid edema. These two cases were diagnosed as they had gastroesophageal reflux disease. They had recurrent attacks of choking and burning sensation. The lesion could not be diagnosed by ultrasound but was diagnosed correctly by a laryngoscope.

Two of 50 patients (4%) had vocal cord dysfunction (VCD). These two girls (ages 11 and 19 years) had inspiratory dyspnea that was not responding to ordinary bronchial asthma treatment; on ultrasonography, they had abnormal adduction of the vocal cords during inspiration. These findings were confirmed by laryngoscope examination. On follow-up and after further laboratory and clinical evaluation, they were diagnosed with myasthenia gravis and received treatment and plasmapheresis. After 8 weeks, their vocal cord mobility was restored to normal and the condition was relieved.

Two of 50 patients (4%) had laryngocele. They presented with neck swelling. They were correctly diagnosed by ultrasound and the diagnosis was confirmed in one patient by MRI and in the other one by CT; these two patients had an infected laryngocele and were drained surgically.

  Discussion Top

Singh et al. [7] , in a volunteer descriptive study, have described the anatomy of the laryngeal structures, showing the pre-epiglottic space, hyoid bone, thyroid cartilage, cricoid cartilage, and vocal cords' sonographic appearance.

Also, Jadcherla et al. [8] and Dennington et al. [9] reported the normal appearance of vocal folds in the pediatric age group as paired hyperechoic linear structures with respiratory and swallowing mobility.

Jadcherla et al. [8] reported the complete visualization of adduction and abduction of the vocal cords and imaged with synchronous correlation by nasolaryngoscopy in 10 children.

In the present study, identification of vocal cord mobility was successful both in the normal cords and in diseased ones in resting and respiratory maneuvers [Figure 1]. In male patients, we had a problem with the calcified thyroid cartilage, which causes intense acoustic shadowing, interfering with the good visualization of vocal cords; this problem was solved by the use of more gel, more pressure, cranial angulation, and respiratory maneuvers. This obstacle was described by Rubin et al. [10] and was resolved by the same technique.
Figure 1:

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In the children and young females who have a nonheavy calcified thyroid cartilage, the vocal cords and laryngeal interior structures appear easier and well demarcated, even the posterior glottic area and interarytenoid area, which is in agreement with Loveday [11] , who reported that the prevalence and degree of calcification are typically less in the female.

Laryngeal cancer is a common malignant neoplasm of the head and neck, with a high incidence, accounting for 2.4% of new malignancies worldwide every year [12] .

Accurate pretherapeutic staging has a huge impact on treatment planning (i.e. radiation therapy, voice-preserving partial laryngectomy or total laryngectomy, endoscopic laser resection, and a combination of modalities) [13] .

Ultrasound has an advantage over laryngoscopy in detecting thyroid cartilage infiltration for cancer glottis as Schade et al. [14] reported that ultrasound could identify thyroid cartilage infiltration; in addition, Gryczyñski et al . [15] reported that ultrasonography is effective in the detection of metastases of laryngeal carcinoma to the lymphatic system of the neck. Other authors noted that high-resolution ultrasound is a sensitive, simple, and inexpensive method for the evaluation of laryngeal cancers and subclinical cervical lymph node and metastasis [16],[17],[18] . Thus, assessment of the laryngeal tumor and its lymph nodes affection can be performed using one technique and at the same time [19] .

In the present study, we aimed to assess whether ultrasound could correctly identify the site and echo pattern of neoplastic lesions. Ten patients with laryngeal cancers were evaluated by the systematic ultrasound (HRLU) technique before any surgery or radiation therapy was received.

Nine of 10 tumors were visible on ultrasound and the site was identified correctly in each. Spread to the pre-epiglottic space was also shown in two cases (20%). Infiltration of thyroid cartilage was identified in three cases (30%) [Figure 2].
Figure 2:

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One of the important advantages of ultrasound over CT and MRI is the ability to evaluate the mobility of the vocal cord on a real-time basis as vocal fold movement can be assessed easily by scanning transversely in the midline; even in the heavily calcified larynx, there is usually a small acoustic window [11] .

Unilateral vocal fold paralysis most commonly occurs following a surgical iatrogenic injury to the vagus or the recurrent laryngeal nerve; thus, a history of head and neck, skull base, brainstem, or chest surgery should be obtained. Specifically, thyroidectomy, carotid endarterectomy, anterior cervical spine surgery, thoracic, or mediastinal surgery has been known to result in unilateral vocal fold paralysis [20] .

Shaath et al. [21] , in a study that included 100 children who had cardiac surgery and presented with significant signs of upper airway obstruction, the results of invasive fiber-optic laryngoscope and noninvasive ultrasonography investigations were compared. The incidence of vocal fold immobility after cardiothoracic surgery was 8%. These eight patients were younger and weighed less than patients with normal vocal fold movement.

Khalil et al. [19] , in their study, concluded that the ultrasound has the same diagnostic ability as the laryngoscope in the assessment of the vocal cord mobility.

Vats et al. [22] reported 81% concordance between ultrasonic and endoscopic findings in vocal folds of young patients.

In the present study, we had 10 patients who had been diagnosed with vocal cord palsy (nine unilateral, one bilateral) because of different causes (postsurgical operations, tumor invasion, or idiopathic); they were all diagnosed well by the HRLU technique by direct visualization of the vocal cords' movements during respiration or when respiratory maneuvers were used [Figure 3].
Figure 3:

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El-Hennawi et al. [23] concluded that ultrasonography, with special precautions, was the modality of choice for assessment of patients with bilateral vocal cord paralysis; this was in agreement with our study as there was one case of bilateral vocal cord paralysis that was noted to be fixed in position because of invasion by laryngeal cancer.

In the present study, the evaluation of ultrasound for detection of vocal cord ulceration, nodules, and interarytenoid edema showed that ulceration could not be detected by ultrasound as our four patients with vocal cord ulceration were well identified by ultrasound because the ulcers are usually very superficial, which may make the air-soft tissue interface obliterate it; also, two cases of interarytenoid edema were not detected by ultrasound as they were far from the probe, with the obstacle of calcified thyroid cartilage. Also, the three vocal cord nodules could not be seen; all nine lesions (ulcers, nodules, and interarytenoid edema) were well diagnosed by a laryngoscope; hence, a laryngoscope was more useful and this is in agreement with Khalil et al. [19] , who studied 242 patients known to have a vocal cord lesion pre-examined by rigid laryngoscopy and 125 nonsmoker volunteers, comprising the control group, and reported that 'surface ulceration was not detected in any case and interarytenoid edema could not be detected as the arytenoid and interarytenoid area could not be identified by ultrasound'.

In the present study, we had three patients with polyps; ultrasound could detect only one polyp [Figure 4].
Figure 4:

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This was in agreement with Rubin et al. [10] as they reported in a study that used grayscale ultrasound of the larynx carried out in 29 patients with a swelling of the true vocal fold and dysphonia that 'nodules and/or polyps along the epithelial verge of the vocal fold could not be visualized with the ultrasound'.

In a study by Rubin et al. [10] , grayscale ultrasound of the larynx was carried out in 29 patients with a swelling of the true vocal fold and dysphonia. The findings were then compared with subsequent microlaryngoscopy. Preoperative laryngeal ultrasound correctly predicted the surgical findings of a cystic lesion in five of 11 cases; it correctly identified that no cyst was present in 15 of 16 instances.

In the present study, two cysts of the true vocal fold were identified, on ultrasound, as ovoid shaped, 4 and 13 mm diameter, echo-poor structures. Increased sound transmission was not clearly seen and the superficial border was not as clear as the deep border, and they were near the anterior commissure; thus, they were visualized easily, and we missed one cyst as it was very small (≥3 mm superficial to the left vocal cord edge [Figure 5].
Figure 5:

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VCD, also commonly known as paradoxical vocal fold motion, can be characterized as an abnormal adduction of the vocal cords during the respiratory cycle (especially during the inspiratory phase) that produces airflow obstruction at the level of the larynx [24],[25],[26] .

VCD frequently mimics persistent asthma and is often treated with high-dose inhaled or systemic corticosteroids, bronchodilators, multiple emergency department visits, hospitalizations, and, in some cases, tracheostomies and intubation [24],[25],[26],[27],[28],[29] .

In the present study, there were two patients (female children) diagnosed with VCD as they had myasthenia gravis disease. They had sluggish vocal cord mobility during inspiration and were diagnosed previously as bronchial asthmatic attacks' after they received myasthenia treatment regimen, the condition improved.

This condition was reported by Gaafar and Fasyh [30] in their study, which included five children (three boys and two girls) who had VCD; three of them had myasthenia gravis.

Loveday [11] described the ultrasonic criteria of the laryngocele when obstructed and fluid-filled (laryngeal cyst) that is easily seen with ultrasound and less suitable for assessment of the size and extent of the air-filled laryngocele. In the present study, we had two cases of infected laryngocele well characterized by ultrasound and confirmed by CT and MRI studies [Figure 6].
Figure 6:

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We acknowledge the limitations to the study. The linear transducers or even convex curved transducers do not conform to the neck anatomy and this may contribute to limiting views. These technical issues may be resolved by the development of a concave curve high-frequency transducer for adequate maintenance of contact between the probe and skin surface; this concave curve ultrasound probe may be essential for the ultrasound assessment of the airway and airway-related anatomical structures as the standard of care.

  Conclusion Top

HRLU is a promising technique in neck imaging. It utilizes ultrasound waves that are considered safe, cheap, and widely available and utilizes no ionizing radiation. It is suitable for claustrophobic, restless, or uncooperative patients and is highly valuable in the pediatric age group.

HRLU is a perfect complementary tool in the scope of neck imaging modalities that is highly useful and saves a lot, and it requires no special training or extensive settings; it can be learned and performed easily.

HRLU is an effective diagnostic tool for the proper assessment of the vocal cord lesions and mobility and in cases with laryngeal tumors, but is less effective in vocal cord ulcers and small lesions because of a limitation of the air-mucosa interface.

In the present study, ultrasound complemented the clinical assessment and was thus useful in patient diagnosis, staging, or management.

We still need more studies to determine its role on a wider scale and in a focused manner.

  Acknowledgements Top

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4]


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