Laryngeal Ultrasound: What can we see? Julina Ongkasuwan, MD, FAAP, FACS Adult and Pediatric Laryngology
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1 Laryngeal Ultrasound: What can we see? Julina Ongkasuwan, MD, FAAP, FACS Adult and Pediatric Laryngology
2 Page 2 xxx00.#####.ppt 12/20/2016 3:24:18 PM
3 Page 3 xxx00.#####.ppt 12/20/2016 3:24:19 PM
4 Outline Historical Perspective Principles of Ultrasound Vocal Fold Mobility in Infants Laryngeal Lesions
5 Historical Perspective 1880 Pizoelectric effect WWI to WWII SONAR (SOund Navigation And Ranging) 1935 RADAR ( RAdio Detection And Ranging) 1930 s Medical therapy and ablation 1940 Diagnostic tool 1.2MHz 1949 A-mode ultrasound 1953 B-mode ultrasound 1953 Echocardiogram 1960 s OB applications 1970 The American Society of Ultrasound Technical Specialists aka Society of Diagnostic Medical Sonography Newman PG, Rozycki GS. The history of ultrasound. Surg Clin North Am. 1998Apr;78(2): Page 5 xxx00.#####.ppt 12/20/2016 3:24:19 PM
6 Surgeon performed ultrasound Page 6 xxx00.#####.ppt 12/20/2016 3:24:19 PM
7 Page 7 xxx00.#####.ppt 12/20/2016 3:24:19 PM
8 Outline Historical Perspective Principles of Ultrasound Vocal Fold Mobility in Infants Laryngeal Lesions
9 Principles of Ultrasound Page 9 xxx00.#####.ppt 12/20/2016 3:24:19 PM
10 Principles of Ultrasound Medium Velocity (m/s) Acoustic Impedance (10 6 Rayls) Attenuation Coefficient (db/cm at 1MHz) Air Water Blood 0.18 Fat Brain Liver Kidney Muscle Soft Tissue Bone Page 10 xxx00.#####.ppt 12/20/2016 3:24:20 PM
11 Artifacts Air Artifact Acoustic shadowing Acoustic enhancement Reverberation Refraction Comet-tail Mirror-image Ghosting Beam-width Ring-down Speed displacement Page 11 xxx00.#####.ppt 12/20/2016 3:24:20 PM
12 Outline Historical Perspective Principles of Ultrasound Vocal Fold Mobility in Infants Laryngeal Lesions
13 Vocal fold movement impairment (VFMI) Neuronal injury % after infant aortic arch surgery TCH 27% 12-22% after adult aortic surgery BCM - 32% extent I/II aortic repair (unpublished data) Thyroidectomy 1-2% Mechanical fixation Posterior glottic stenosis, Cricoarytenoid joint fixation Morbidity of VFMI Stridor (infants) Aspiration Impaired pulmonary toilet Increased length of stay Pereira KD et al. Int J Pediatr Otorhinolaryngol 2006; 70: Benjamin JR et al. Journal of perinatology 2010; 30: Zbar RI et al. Ann Thorac Surg 1996; 61: Clement WA et al. Arch Otolaryngol Head Neck Surg 2008; 134: Dewan K etal. Laryngoscope; 122: Skinner ML et al. J Thorac Cardiovasc Surg 2005; 130: Averin K et al. Ann Thorac Surg; 94: Page 13 Teixido MT, Leonetti JP Oto HNS. Feb 1990;102(2): Ohta N, et al. Journal of vascular surgery. Apr 2006;43(4): Itagaki T, et al. The Annals xxx00.#####.ppt of thoracic 12/20/2016 surgery. 3:24:20 Jun PM2007;83(6):
14 Background Morbidity of FNL Epistaxis 1% Bradycardia 2% Physiologic shifts BP, pulse, O 2 sat Congenital heart disease De Oliveira: Early circulatory collapse in 24% of children after Norwood 64% mortality rate for those patients Friedman EM. Ann Otol Rhinol Laryngol 1997; 106: Paul BC et al. Ann Otol Rhinol Laryngol 2012; 121: Grundfast KM, Harley E. Otolaryngol Clin North Am 1989; 22: De Oliveira NC et al. Circulation 2004; 110:II Page 14 Fan LL, Flynn JW. Laryngoscope 1981; 91: Berger RM et al. Lancet 2012; 379: Smith MM et al.int J Pediatr Otorhinolaryngol 2007; 71: Ongkasuw an J, et al. Laryngoscope Ongkasuw an J et al. Laryngoscope; 122: xxx00.#####.ppt 12/20/2016 3:24:20 PM
15 Background Limitations of Flexible Nasolaryngoscopy (FNL) Extensive movement Excess secretions Retroflexed or omega epiglottis Floppy arytenoids Intrarater reliability vocal fold mobility in infants Normal vs. VFMI k= paresis vs. paralysis k= Intra-rater reliability ranged from moderate to perfect agreement (k = ) Page 15 xxx00.#####.ppt 12/20/2016 3:24:20 PM
16 Cry Volume in db Cry volume in vocal fold paralysis Normal VFMI p Correlation to db 42 NICU and CVICU post-extubation infants 21 with and 21 without VFMI Smartphone app Sound Meter (ver 1.6), Smart Tools Co.) 12 inches from patient s head Peak measurements x3 (in db) while patient crying Gender (female) Age at scope (days) Duration intubation (days) Volume (db) Normal vocal fold mobility Vocal Fold Movement Impairment Page 16 xxx00.#####.ppt 12/20/2016 3:24:20 PM
17 Infant with normal vocal fold mobility after extubation Page 17 xxx00.#####.ppt 12/20/2016 3:24:20 PM
18 Results Receiver Operating Characteristic Curve Cry volume vs. VFMI Area under the ROC = Cry volume vs. Aspiration Area under the ROC curve = Page 18 xxx00.#####.ppt 12/20/2016 3:24:20 PM
19 Results Mean Cry Volume (db) Vocal Fold Movement Impairment Aspiration Sensitivity (%) Specificity (%) Sensitivity (%) Specifcity (%) Page 19 xxx00.#####.ppt 12/20/2016 3:24:21 PM
20 History of Laryngeal Ultrasound MHz probe Adults: Laryngeal Ultrasound (LUS) vs. FNL Sensitivities 67% % Specificities from 89% % Hu et al (6-13MHz) visualization of endolarynx > age 60 years 38.1% <18 years 100% Wong KP, et al.. Surgery; 154: ; discussion Hu et. al. J Ultrasound Med; 29: Wong KP, et al. Annals of surgical oncology 2015; 22: Page 20 Amis RJ, et al. Middle East J Anesthesiol; 21: Sidhu S, et al. ANZ J Surg 2001; 71: Wong KP, et.al. Surgery 2014; 156: ; discussion xxx00.#####.ppt 12/20/2016 3:24:21 PM
21 Calcification Based on CT Thyroid cartilage calcifies by 1.5% to 4% per year. Posterolateral to anteromedial direction mean patient age thyroid cartilage denser than soft tissue (300 HU) 40 yrs (standard deviation 7.71) Frequency? 12-5 MHz vs 9-3 MHz Other factors? Gender Race BMI Wenaas AE, Tran B, Ongkasuwan J. The progression of thyroid cartilage calcification as it relates to the utilization of laryngeal ultrasound. Laryngoscope Apr;126(4):913-7 Woo JW, Park I, Choe JH, Kim JH, Kim JS. Comparison of ultrasound frequency in laryngeal ultrasound for vocal Page cord 21 evaluation. Surgery Nov 18. Kandil E, Deniwar A, Noureldine SI, Hammad AY, Mohamed H, Al-Qurayshi Z, Tufano RP. Assessment of Vocal Fold Function Using Transcutaneous Laryngeal Ultrasonography and Flexible Laryngoscopy. JAMA Otolaryngol Head Neck Surg Jan;142(1):74-8 xxx00.#####.ppt 12/20/2016 3:24:21 PM
22 Vocal Fold Mobility in Infants LUS vs. FNL in Children E. Friedman, 1997 (7MHz) Agreement 87% to 94% Weighted kappa values between 0.75 to 0.91 Vats et al., 2004 (7.5MHz) LUS vs. FNL in infants <12 mo age Concordance rate 77.7% Friedman EM. Role of ultrasound in the assessment of vocal cord function in infants and children. Ann Otol Rhinol Laryngol 1997; 106: Vats A, Worley GA, de Bruyn R, Porter H, Albert DM, Bailey CM. Laryngeal ultrasound to Page assess 22 vocal fold paralysis in children. J Laryngol Otol 2004; 118: xxx00.#####.ppt 12/20/2016 3:24:21 PM
23 Purpose #1 Compare LUS to FNL in recently extubated post-surgical CVICU neonates and the ability to identify VFMI #2 Compare the physiologic impact of FNL versus LUS on blood pressure, pulse, and oxygen saturation #3 Determine LUS measurements that can determine mobility Page 23 xxx00.#####.ppt 12/20/2016 3:24:21 PM
24 Methods 46 consecutive CVICU post-op infants 23 with and 23 without VFMI Exclusion criteria FNL could not be performed or was non-diagnostic Tracheotomy Inability to extend the neck GE Logic E9 ultrasound, 51 mm length 15 MHz linear probe LUS reviewed by 2 pediatric radiologists blinded to mobility Page 24 xxx00.#####.ppt 12/20/2016 3:24:21 PM
25 Results Page 25 xxx00.#####.ppt 12/20/2016 3:24:22 PM
26 Results #1 Identification of VFMI Intra-rater reliability for LUS k=0.94 Inter-rater reliability LUS k=0.78 LUS vs. FNL k=0.78 Page 26 xxx00.#####.ppt 12/20/2016 3:24:22 PM
27 Results #2 Physiologic Impact Page 27 xxx00.#####.ppt 12/20/2016 3:24:22 PM
28 Results #3 Measurements Page 28 xxx00.#####.ppt 12/20/2016 3:24:22 PM
29 Results #3 Measurements Page 29 xxx00.#####.ppt 12/20/2016 3:24:22 PM
30 Outline Historical Perspective Principles of Ultrasound Vocal Fold Mobility in Infants Laryngeal Lesions
31 Background FNL Causes changes in heart rate, blood pressure, and oxygen saturation 25% of adults report gagging 10% have dyspnea For children: 2 or more adults to restrain the child Rigid transoral 70 degree laryngoscopy 18% 3 year olds 66% of 6 and up Ongkasuwan J, Yung KC, Courey MS. The physiologic impact of transnasal flexible endoscopy. Laryngoscope; 122: Ongkasuwan J, Ocampo E, Tran B. Laryngeal ultrasound and vocal fold movement in the pediatric cardiovascular intensive care unit. Laryngoscope Page 31 Paul BC, Rafii B, AchlatisS, Amin MR, Branski RC. Morbidity and patient perception of flexible laryngoscopy. Ann Otol Rhinol Laryngol 2012; 121: xxx00.#####.ppt 12/20/2016 3:24:22 PM
32 Page 32 xxx00.#####.ppt 12/20/2016 3:24:22 PM
33 Laryngeal Ultrasound and Vocal Fold Lesions Adults Rubin et al. (5-10 MHz probes, 29 patients) Sirikci et al. (5MHz probe, 14 patients) Lesions > 2mm in size that project into the lumen Pediatric Bisetti et al. (7.5-12MHz probe) 16 children (mean age 7.5 years) cysts, nodules could be seen Bryson et al. (probe type not specified) 8 children (mean age years) RRP discrete, hyperechoic lesions Sirikci A, KaratasE, Durucu Cet al. Noninvasive assessment of benign lesions of vocal folds by means of ultrasonography. Ann Otol Rhinol Laryngol 2007; 116: Rubin JS, Lee S, McGuinness J, Hore I, Hill D, Berger L. The potential role of ultrasound in differentiating solid and cystic swellings of the true vocal fold. J Voice 2004; 18: Page 33 xxx00.#####.ppt 12/20/2016 3:24:22 PM
34 Purpose #1 Compare LUS to FNL to identify vocal fold nodules vs. normal #2 Determine if ultrasound can be used to reliably measure nodule size and depth Page 34 xxx00.#####.ppt 12/20/2016 3:24:23 PM
35 Methods 46 patients 23 with vocal fold nodules on laryngoscopy 23 normals Exclusion criteria Laryngoscopy could not be performed or was non-diagnostic Tracheotomy Inability to extend the neck GE Logic E9 ultrasound, 51 mm length 15 MHz linear probe LUS reviewed by 2 pediatric radiologists blinded to nodule status Page 35 xxx00.#####.ppt 12/20/2016 3:24:23 PM
36 Results #1 Compare LUS to FNL to identify vocal fold nodules #2 Determine if ultrasound can be used to reliably measure nodule size and depth Page 36 xxx00.#####.ppt 12/20/2016 3:24:23 PM
37 Discussion Small size studies No real time physiologic data Have not determined if it can distinguish between various lesions Cannot assess laryngeal closure High resolution can be used for young children? May need lower resolution for 40 s and up Page 37 xxx00.#####.ppt 12/20/2016 3:24:23 PM
38 QUESTIONS? Page 38 xxx00.#####.ppt 12/20/2016 3:24:23 PM
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