Podcast
Questions and Answers
What condition might be indicated by immobile arytenoids during examination?
What condition might be indicated by immobile arytenoids during examination?
Which observation during an endoscopic examination can help visualize abnormalities of the valleculae?
Which observation during an endoscopic examination can help visualize abnormalities of the valleculae?
Which finding is NOT typically associated with laryngeal irritation or laryngopharyngeal reflux?
Which finding is NOT typically associated with laryngeal irritation or laryngopharyngeal reflux?
Which statement about intra-rater and inter-rater reliability is accurate?
Which statement about intra-rater and inter-rater reliability is accurate?
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What aspect of laryngeal examination does thickened mucus primarily indicate?
What aspect of laryngeal examination does thickened mucus primarily indicate?
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Study Notes
Endoscopy Assessment
- Endoscopy with continuous light shows laryngeal structure and gross movement.
- It allows observation of aspects like vocal fold motion, mucus, vascularity, supraglottal activity, and vocal fold edge shape.
- Laryngeal structure abnormalities (e.g., valleculae, piriform sinuses, epiglottis) can be noted.
- Lowered pitch during "ee" widens the angle for better visualization.
- Omega-shaped epiglottis is a common male variant.
- Signs of irritation or reflux (edema, erythema, cobblestoning) are observed.
- Reliability of findings, especially with flexible fiberoptic laryngoscopy, is often poor.
- Arytenoid mobility and symmetry are assessed to evaluate cricoarytenoid joint and recurrent laryngeal nerve integrity.
- Mobility is best seen during phonation and rapid inhalation ("ee"-sniff or coughing).
- Rapid pitch glides help assess symmetry of pharyngeal wall bulges.
- Petiole tilting during pitch glide suggests superior laryngeal nerve weakness.
Mucus Assessment
- Thickened mucus can adhere to vocal fold edges or surfaces.
- Thick mucus often relates to lack of hydration or chronic irritation (trauma, smoking, reflux).
- Mucus pooling in pyriform sinuses might indicate poor laryngeal sensation or inefficient swallowing.
- Mucus can mimic lesions, requiring clearing via swallowing or coughing for accurate assessment.
Vascularity Assessment
- Erythema (blush) signifies vocal fold hyperemia.
- Normal capillaries are aligned parallel to the free edge.
- Abnormally dilated, tortuous vessels (capillary ectasias/microvarices) suggest stiffness or hemorrhage risk (especially at the vocal fold edge).
- Hemorrhage results in a yellow-brown discoloration.
- Increased vascularity of certain structures (folds, ventricles, arytenoids, epiglottis) is common in women premenstrually.
Supraglottal Activity Assessment
- Normal supraglottal activity includes lateral wall constriction with increasing pitch, and epilaryngeal space narrowing.
- Aryepiglottic narrowing/dilation changes with vowels in speech.
- Tremor/myoclonic movements indicate neurological impairment.
- Mild supraglottal constriction during phonation initiation is normal.
- Sustained supraglottal constriction suggests muscle tension dysphonia (primary or secondary).
- Altering the phonation target ("oo," "m," or slightly increased pitch) or phonation on inhalation may decrease constriction, allowing better visualization for evaluating etiology.
- Voice therapy is recommended if necessary (and visualization improves).
Vocal Fold Edge Assessment
- Straightness/smoothness and irregularities of vocal folds are assessed.
- Convex or concave ("bowed") vocal fold edges should be noted (bowing isn't a disorder itself).
- Describing irregularities and bowing helps identify potential underlying disorders.
Endoscopy Protocol
- Typical tasks for endoscopic exams are detailed.
- Rapid repetition rate of "ee" and "hee" (4-6 syllables/second) is normal.
- Difficulty with rhythmic voice onset/offset suggests neurological impairment.
- Assessing connected speech (phrases, sentences, conversation) is needed if sustained vowel quality is inconsistent with interview.
- Laryngeal sensation can be roughly assessed by touching the posterior aryepiglottic folds with the endoscope.
- Sensory threshold testing (FEESST) offers a more precise method for assessing laryngeal sensation.
- Velopharyngeal function assessment is necessary if nasal emission or hypernasality is present.
Limitations of Endoscopy
- Endoscopy, while common, provides limited insights into the complete picture of a voice disorder.
- Structural observations are less detailed than other techniques.
- Vocal fold vibration patterns are not observable.
- To analyze vocal fold vibration, specialized lighting is needed.
Stroboscopy Assessment
- Videostroboscopy assesses vocal fold vibration patterns.
- Vocal fold physiology during different phonation modes needs understanding.
- Healthy vocal folds have a pliable cover (epithelium & superficial lamina propria) and a stiffer body (intermediate/deep lamina propria & thyroarytenoid muscle).
- Muscle contraction positions and shapes vocal folds for vibration.
- Vocal fold vibration relies on aerodynamic and elastic forces.
- Two basic movement patterns are (1) lateral displacement of the folds and (2) a vertical phase difference (inferior portion leading in movement).
- Vocal fold vibration generates a series of air pulses - "glottal flow".
- To visualize fast (100+ Hz) vibration patterns, videostroboscopy is required.
- Strobe light illuminates vocal folds across vibratory cycles.
- Strobe timing relies on predicting the fundamental frequency (Fo).
- Incorrect prediction leads to incorrect visualization of vibration.
- Strobe light can be used in a stop (locked) mode to create the illusion of no movement.
- Stroboscopy is valuable for assessing stiffness, scar tissue, lesions, asymmetry, and postoperative healing.
- Stroboscopy may change or refine diagnoses in 30-47% of cases with flexible endoscopy.
- Multiple rating scales for vocal fold vibration patterns and mucosal pliability exist.
- Reliability of ratings varies depending on parameter and study.
- The VALI form (Voice-Vibratory Assessment with Laryngeal Imaging Form) appears to improve inter/intra-rater reliability through standardized parameter definitions and illustrations.
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Description
This quiz explores the key aspects of endoscopy assessment focused on laryngeal structures. It covers the importance of visualizing vocal fold motion, identifying anatomical abnormalities, and evaluating laryngeal nerve integrity. Test your knowledge on the techniques and findings associated with this diagnostic procedure.