VOCAL FOLDS: GRAY SCALE SONOGRAPHIC

ASSESSMENT WITH SONO-CT EFFECT

MANAL MS HAMED1, MD AND MOHAMAED EL-SHINNAWI2, MD

Assistant Professor of Radiodiagnosis1 and Lecture of Otorhinolaryngology 2,
Ain Shams University.

ABSTRACT
The aim of this study was to determine the role of ultrasound, utilizing the sono-CT effect, in
the assessment of vocal folds. This study included 40 control group and 30 patients; the latter
was divided into patients with disphonia (n=25) and patients with vocal folds paralysis (n=5).
The participants underwent flexible laryngoscopy and ultrasound for the vocal folds. The
results included patients with cysts (n=5), polyps (n=8) and Reinke’s edema (n=12), unilateral
vocal fold paralysis (n=4) and bilateral vocal cord paralysis (n=1). Ultrasound correctly
diagnosed all cysts and cord paralysis. It missed one polyp and one Reinke’s edema. There
was statistical correlation between the gender and the vocal folds thickness in the control
group (p<0.001). The sensitivity of the ultrasound in relation to endoscopy was 93%, the
specificity was 100% and the accuracy was 97.1%. In conclusion, ultrasound of the larynx,
utilizing the sono-CT effect, is a safe, noninvasive technique that can be used as a screening
method for detecting and characterizing benign vocal folds lesion and cord paralysis.

INTRODUCTION
The ideal diagnostic test for the assessment of the vocal folds would be simple, rapid,
non-invasive and accurate. Indirect and direct flexible laryngoscopy are readily
available methods to assess the status of the vocal folds, but they are invasive, can
be unpleasant and uncomfortable procedure for the patients to endure. Indirect
laryngoscopy has reported failure rate 5-20% due to hyperactive gag reflexes, obesity,
and anatomical obstruction.1,2 Flexible direct laryngoscopy allows visualization of the
cords over 99% of cases.2,3 Over and under diagnosis of vocal fold paralysis is quite
common because of splinting of the larynx which may occur with a rigid laryngoscope;
poor visualization to supraglottic collapse; cricoarytenoid fixation and paradoxical
vocal folds movements resulting from Bernoulli effect of airflow through glottis during
inspiration.3
Ultrasound has been posited as a possible mode for investigation of the larynx since
the 1960's.4 By 1973, echoes from the free margins of the true vocal cords could be
"unequivocally identified".5 By the late 1980's ultrasound was found to be useful for
real-time evaluation, not only of the true cords but also of the false vocal cords and the
vocal cords movements.6 Surprisingly little use of ultrasound has been reported in the
pathology of the vocal cords. Some postulated that this maybe due to the general
interest in other more sophisticated imaging modalities, including three-dimensional
CT and MRI.7

The aim of the study was to assess the role of ultrasound in detecting and
characterizing vocal folds’ mobility and abnormalities.

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 MATERIALS AND METHODS

From June 2003 till June 2005, we performed dynamic ultrasound scanning of the
larynx on 70 candidates. They consisted of a control group (n=40) and patients (n=30)
whom were referred to the Ultrasound Department in Jeddah Clinic Hospital from the
Ear, Nose and Throat clinic. The latter was divided into two group including; patients
with disphonia (n=25) due to variable causes of benign vocal folds mucosal disorders,
e.g. Reinkes edema, cyst and polyp, and patients with vocal cord palsy of variable
etiology (n=5). The control group consisted of 20 males and 20 females; all were staff
in Jeddah Clinic Hospital-AlKandarah (JCHK) and participated willingly in the study.
Their age ranged between 18 and 60 years, with the mean age was 36+6SD years.
They were 42 males and 28 were females. All the participants underwent
nasophyryngoscopy and then were sent for the ultrasound study.
The scanning was performed on a Philips 5000 HD scanner using a linear transducer
(10-12Hz) and applying the sono-CT effect (which is a special feature to improve the
resolution of the 2D gray scale image). The patient lied supine with a pillow under the
shoulders and the neck extended. The transducer was placed in the front of the neck
at the cricothyroid membrane after applying abundant amount of gel to the front of the
neck. The transducer is moved from up downwards till the vocal cords are identified
as two echogenic mobile obliquely oriented structures (fig 1-4). Detailed scanning of
the larynx was then conducted including; i) vocal cords’ echogenicity and calcifications
(fig 5, 6); mobility, echogenicity, thickness and masses, ii) the glottic chink
measurement, and iii) arytenoids mobility.
The uncalcified thyroid cartilage was the window for scanning. The main limitation of
our technique was the calcified cartilage, in old aged males, as it casted acoustic
shadowing upon the larynx, causing image degradation. In order to overcome this
limitation the probe was placed bellow the thyroid cartilage and was angulated up, but
the quality of the image obtained was poor and this adaptation was abandoned (fig 5).
The radiology consultant was blinded to the flexible laryngoscopy results. The
sonographic findings were then compared to the flexible laryngoscopic results.
Statistical analysis was performed by the SPSS 10. The sensitivity, specificity and
accuracy for detection and characterization of vocal folds benign lesions and mobility
were calculated.

RESULTS
Each cord appeared as double echogenic lines with a hypoechoic center. It has a
homogenous thickness all though with the arytenoids cartilage seen as an echogenic
oval structure is seen at its base.
There was statistically significant difference in vocal folds' thickness between males
and females in the control group (p<0.001). The vocal cord thickness was 1.1-1.4 mm
in females with the mean 1.2+0.9SD and they measured 1.7-2.0mm in males with the
mean of 1.7+0.8SD. Five female patients had verilizing sound and their vocal folds'
thickness resembled those of the males. There wasn't statistically significant
difference in vocal folds' thickness in males and females regarding their age and the
laryngeal chink, where the mean was 6.6+5.8SD in male and 6.2+7.7SD in females,
(p =0.123).
The patients with benign vocal fold lesions (n=25) included; vocal fold cysts (n=5),
polyps (n=8) and Reinkes edema (n=12). Ultrasound and endoscopy correctly
detected all the cysts, three were in the left vocal fold and two were in the right.

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Ultrasound diagnosed 7/8 of the polyps; while endoscopy diagnosed 8/8 (i.e. one case
was false negative). 11/12 of the Reinkes edema were diagnosed by ultrasound while
all were detected by endoscopy (i.e. one case was false negative). There were no
false positive cases, i.e. no patient was misdiagnosed with cord's abnormality in
contrast to a normal endoscopic findings.
Ultrasound was able to detect all cases of cord paralysis, which included; unilateral
paralysis (n=4) and bilateral paralysis with tracheostomy (n=1). We scanned five
cases with laryngeal carcinoma who under went computed tomography and
endoscopy. They weren't included in this study as their ultrasound scanning was
unsatisfactory in spite of cephalic angulations of the probe to avoid thyroid cartilage
calcification.
The sensitivity of the ultrasound detection and characterization of vocal folds'
pathology was 93%, the specificity was 100% and the overall accuracy was 97.1%.

DISCUSSION
Laryngeal ultrasound is a safe, noninvasive technique with accuracy comparable to
laryngoscopy, which is accepted as the current gold standard. It is painless, doesn't
require sedation and hence it is well tolerated by the patients and their families.
Furthermore, it is a short procedure lasting approximately 15 minutes and the results
are recorded for review and evaluation later. The main disadvantage is that it is
operator-dependent and requires a degree of cooperation from the patient.3 In our
study we agree with Vats (2004)3, but we have an additional limitation due to thyroid
cartilage calcifications (fig 5).
We found a statistically significant difference in vocal folds thickness between males
and females, but no significant difference regarding age in both sexes. There was no
variation in the length of the vocal folds or in the width of glottic chink in both sexes.
However, these findings were not reported previously in the literature, and need to be
emphasized in future multiple studies and with larger groups.
Some authors reported that vocal folds were hypoechoic and attributed this to their
high muscle content, while the vocal ligament which is the free edge of the cord
appeared as an echogenic band 8. On the other hand, in our study we visualized the
entire vocal fold. It was seen as two echogenic lines with a hypo dense area in
between which anchored in the hyperehoic arytenoids. Theses findings were
represented in the histopathological structure of the vocal folds, (correlated with
mucosal thickness measurements), where first echogenic layer corresponds to a
boundary echo or the epithelium plus the superficial layer of lamina propria, the
hypodense area represents the intermediate layer of lamina propria with abundant
elastic fibers, and the second ecchogenic line corresponds to the deep layer of lamina
propria.9
Sonographic assessment of vocal fold mobility could be of crucial clinical importance
in cases of stridor, in pre-operative and post operative assessment of vocal fold
mobility especially in absence of other tools like stroboscopy or in cases with difficult
indirect laryngoscopy. Ooi et al in 1989 10 and in 1992 11 reported low percentage of
ultrasound concordance with clinical assessment of vocal cords paralysis (64% and
62%). Sidhu et al in 20018 reported low sensitivity (62%) and high specificity (97%) in
detecting vocal cords mobility, and they attributed their results to the learning curve
and due to vibration of the vocal cords by passage of air causing their vibrations. Vats
et al in 2004 3 assessed vocal fold paralysis in children and reported higher
percentage of ultrasound concordance (81.8%). In contrary we clearly visualized the

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entire length of vocal cords and followed their movements and in contrast our
sensitivity was 93%, specificity was 100% and over all accuracy was 97.1%. We
attributed the higher concordance of our study to the implication of more sophisticated
ultrasound tool than that used in the last decade.
In our study we measured the width of the glottic chink. This could be of great value in
assessing and following up of airway patency. We correctly reported all cysts (fig 7),
and the first to diagnose polyps (fig 8) and Reinkes edema (fig 9), as these two
findings were not previously reported in the ultrasound literature.
Rubin et al in 2004 7 missed few solid lesions in the vocal cord, although they saw the
edges clearly. They attributed this to the minor reverberation artifacts, due to the air-
soft tissue interfaces, which caused inherent problems to ultrasound because air
scatters the beam. We did not encounter this problem due to the high resolution, high
frequency (10-12MHz) and the sophisticated software as the Sono-CT effect of the
images. On the other hand, we missed a case of polyp and Reinkes edema. We
attributed this acutely angulated thyroid cartilage causing difficulty during scanning.

CONCLUSION
In conclusion, ultrasound is an accurate, safe and noninvasive tool for assessment of
vocal fold appearance, lesions and mobility, with the only limitation is the thyroid
cartilage calcifications. It can be used as a first line of investigation for vocal folds
mobility, abnormalities and for follow up of laryngeal airway patency.

References:

1. Curley JWA and Timms MS. Incidence of abnormality in routine vocal cord examination. J
Larngol. Otol. 1989; 103: 1057-1058.
2. Lacost L, Karayan J and Lahuede MS. A comparison of direct, indirect and fibreoptic
laryngoscopy to evaluate vocal cord paralysis after thyroid surgery. Thyroid 1996; 6: 14-21.
3. Vates A, Worly GA, De Bruyn R, Porter H, Albert DM and Bailey CM. laryngeal ultrasound
to asses vocal cord paralysis in children. J Laryngol. Otol. 2004; 118: 429-431.
4. Herz CH, Lindstorm K and Sonesson B. Ultrasonic recording of the vibrating vocal folds.
Acta Otolaryngol. 69: 223-230, 1970. Quoted form Rubin JS, Lee S, McGuinness J, Hore I, Hill
D and Berger L. The potential role of ultrasound in differentiating solid and cystic swellings in
the true vocal fold. J of Voice 2004; 18(2): 231-235.
5. Holmer NG, Kitzing P and Lindstorm K. Echo glottography. Acta Otolaryngol 75: 454-463,
1973. Quoted form Rubin JS, Lee S, McGuinness J, Hore I, Hill D and Berger L. The potential
role of ultrasound in differentiating solid and cystic swellings in the true vocal fold. J of Voice
2004; 18(2): 231-235.
6. Raghavendra BN, Horii Sc, Reede DL, Rumancik WM, Persky M and Bergeron T.
Sonographic anatomy of the larynx, with particular reference to the vocal cords. J Ultras. Med.
1987; 6(5): 225-230.
7. Rubin JS, Lee S, McGuinness J, Hore I, Hill D and Berger L. The potential role of ultrasound
in differentiating solid and cystic swellings in the true vocal fold. J of Voice 2004; 18(2): 231-
235.
8. Sidhu S, Staton , Shahidi S, Chu j, chew S and Campell P. Initial experience of vocal cord
evaluation using grey-scale, real-time, B-mode ultrasound. ANZJ Surg. 2001; 71:737-739.
9. Etsuyo T, Kitahara S and Kohno N. Intralryngeal application of a miniaturized ultrasonic
probe. Acta Otolaryngol 2002; 122: 92-95.
10. Ooi LLPJ. B-mode ultrasound assessment of vocal cord functions in recurrent laryngeal nerve
palsy. Ann. Acad. Med Singapore 1992; 12: 62: 871-872. Quoted from Sidhu S, Staton ,
Shahidi S, Chu j, chew S and Campell P. Initial experience of vocal cord evaluation using grey-
scale, real-time, B-mode ultrasound. ANZJ Surg. 71:737-739, 2001.
11. Ooi LLPJ, Chan HS and Soo KC. Color Doppler imaging for vocal cord palsy. Haed Neck
1995; 17: 20-23.

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 B

Fig: 1 Fig: 2

Fig 1: normal appearance of the vocal folds. Fig 2: the vocal folds are seen and the laryngeal
It is formed of two echogenic lines with a chink in between having normal measurements
hypoechoic area in between (white arrows). (in between asterisks).

Fig: 3 Fig: 4

Fig 3: thyroid cartilage calcifications casting Fig 4: vocal folds. The vocal cords are
posterior shadowing upon the larynx. The adjacent to the midline (white arrows).
vocal folds are not visualized.

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 Fig: 6
Fig: 5

Fig 5: a 2.2mm cyst is seen in the left vocal Fig 5: a polyp is seen medial to the right vocal
fold near its anchor in the aretynoid cartilage fold, mildly echogenic, encroaches upon the
(white arrow). chink (white arrow) and it measures 4.1x1.4 mm

Fig: 7

Fig 7: Reinkes edema near the base of the right vocal

fold (white arrow). It appears as an illdefined echogenic
area causes thickening of the fold.