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Laryngeal Electromyography: Clinical Application

*Robert T. Sataloff, Phurich Praneetvatakul, Reinhardt J. Heuer, *Mary J. Hawkshaw, *Yolanda D.


Heman-Ackah, Sarah Marx Schneider, and {Steven Mandel, *z{Philadelphia, Pennsylvania, yBangkok,
Thailand, and xSan Francisco, California

Summary: Laryngeal electromyography (LEMG) is a valuable adjunct in clinical management of patients with voice
disorders. LEMG is valuable in differentiating vocal fold paresis/paralysis from cricoarytenoid joint fixation. Our data
indicate that visual assessment alone is inadequate to diagnose neuromuscular dysfunction in the larynx and that diagnoses based on vocal dynamics assessment and strobovideolaryngoscopy are wrong in nearly one-third of cases, based
on LEMG results. LEMG has also proven valuable in diagnosing neuromuscular dysfunction in some dysphonic patients
with no obvious vocal fold movement abnormalities observed during strobovideolaryngoscopy. Review of 751 patients
suggests that there is a correlation between the severity of paresis and treatment required to achieve satisfactory outcomes; that is, LEMG allows us to predict whether patients will probably require therapy alone or therapy combined
with surgery. Additional evidence-based research should be encouraged to evaluate efficacy further.
Key Words: Laryngeal electromyographyElectromyographyVocal fold paresisVocal fold paralysisVocal fold
fixation.

INTRODUCTION
Laryngeal electromyography (LEMG) is a technique to assess
the integrity of laryngeal nerves and muscles. It was introduced
in 1944 by Weddel et al1 and developed further by FaaborgAndersen, Buchtal, and others in the 1950s.24 LEMG has
become increasingly important clinically throughout the last
decade of the 20th century and first decade of the 21st century,
as reviewed by Sataloff et al.5 However, despite extensive use of
LEMG, in a 2003 practice parameter report, Sataloff et al6 highlighted the surprising paucity of high-quality, evidence-based
research confirming or refuting the clinical value of LEMG.
The practice parameter highlighted the need for additional
data regarding the clinical value of LEMG. Several papers published recently have added important information to the literature.723 This report has been prepared to help clarify further the
clinical value of LEMG.
MATERIALS AND METHODS
All subjects are patients of the senior author (R.T.S) and his associates. All subjects had undergone dynamic voice assessment
and strobovideolaryngoscopy with flexible and rigid endoscopes, using a protocol that has been published previously.25
If laryngeal movement abnormalities or asymmetries were
seen, patients were referred for LEMG. LEMG is easy to perform, presents minimal risk to patients, and is a well-tolerated
in-office procedure. Our patients are referred to a neurologist
(S.M) who is board certified in neurology and in electrodiagnostic
Accepted for publication August 18, 2008.
From the *Department of OtolaryngologyHead and Neck Surgery, Drexel University
College of Medicine, Philadelphia, Pennsylvania; yDepartment of OtolaryngologyHead
and Neck Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand;
zDepartment of Communication Sciences and Disorders, Temple University, Philadelphia,
Pennsylvania; xDepartment of OtolaryngologyHead and Neck Surgery, University of
California, San Francisco, California; and the {Department of Neurology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.
Address correspondence and reprint requests to Robert T. Sataloff, Department of
OtolaryngologyHead and Neck Surgery, Drexel University College of Medicine, 1721
Pine Street, Philadelphia, PA 19103, USA. E-mail: RTSATALOFF@PHILLYENT.COM
Journal of Voice, Vol. 24, No. 2, pp. 228-234
0892-1997/$36.00
2010 The Voice Foundation
doi:10.1016/j.jvoice.2008.08.005

medicine, and much of his practice is dedicated to electromyography. Throughout the course of our collaboration of more than
2 decades, he has agreed to see the authors patients blinded,
without clinical information regarding our laryngoscopic findings. Studies were performed using monopolar electrodes and
either a Teca Synergy with Toshiba Satellite Pro 3400 Series
laptop computer or Dantec Keypoint with Toshiba Satellite
330 CDT laptop computer. Percentage recruitment was assessed subjectively using techniques described previously.5
For the purpose of this paper, a decrease in recruitment of
130% was defined as mild paresis, 3160% was defined as
moderate, 6199% was defined as severe paresis, and paralysis
was defined as no observable recruitment. This strict definition
of paralysis explains why there is a relatively small number of
patients classified as fully paralyzed in this report, because most
patients with immobile vocal folds have some innervation or
reinnervation with a small but detectable recruitment response.
Following IRB approval, data were collected retrospectively,
along with objective voice measurement data (not reported in
this paper), and clinical outcomes information. Data were analyzed to help determine the clinical usefulness of LEMG in the
evaluation of disorders of vocal fold mobility.
Medical record data were reviewed from more than 1,500
patients who underwent LEMG between 1998 and 2002. Inclusion criteria were objective voice measures, flexible and rigid
stroboscopic reports, and laryngeal movement abnormalities
or asymmetries found on strobovideolaryngoscopy. Patients
for whom significant information was not available were
excluded. These inclusion/exclusion criteria reduced the total
number of patients to 751 from more than 1,500 charts reviewed. The 751 patients studied included 492 females
(65.5%) and 259 males (34.5%). The ages ranged from 8 to
85 years, with a mean of 46.6 years (SD 16.7). Four hundred
twenty (55.9%) identified themselves as professional speakers,
23 (3.1%) as amateur speakers with significant voice activity,
and 308 (41%) as not being professional or serious amateur
speakers. There were 144 professional singers (19.2%), 136
amateur singers (18.1%), and 471 non-singers (62.7%).
Seventy-five of the subjects mentioned above identified

Robert T. Sataloff, et al

Laryngeal Electromyography

themselves as both professional singers and professional


speakers, and 16 (2.1%) were both amateur speakers and amateur singers. Past medical history information was reviewed but
was irrelevant to the topic of this paper with a few exceptions.
These included 1 patient (0.1%) with a previous diagnosis of
myasthenia gravis; 115 patients (15.3%) with previously diagnosed thyroid abnormalities; 36 patients (4.8%) who had undergone thyroidectomy; 30 (4%) who had had open chest surgery;
16 (2.1%) who had had cervical spine surgery; and 10 (1.3%)
who had undergone other neck surgery previously (eg, carotid
endarterectomy). Patients who had undergone laryngeal surgery
before our evaluation and LEMG are summarized in Table 1.
LEMG must be interpreted with caution in patients who have
undergone laryngeal surgery, and care must be taken to examine
multiple muscles innervated by the recurrent laryngeal nerve on
each side, because invasive laryngeal procedures can alter EMG
responses and lead to misdiagnosis. For example, if a patient
has undergone previous vocal fold injection into the region of
the thyroarytenoid muscle with a material such as Teflon or
Radiesse or if the patient has had hemorrhage into the muscle
with subsequent fibrosis, recruitment response may be reduced
because the LEMG needle is in an area of scar rather than in
viable muscle. However, this reduced recruitment response
may not reflect recurrent laryngeal nerve paresis. In such cases,
recruitment in the posterior cricoarytenoid muscle may be more
likely to reveal the true condition of the recurrent laryngeal
nerve. Multiple muscles were assessed in all of our patients.
The patients chief complaints included hoarseness in 547
(72.8%) patients, vocal fatigue in 89 (11.9%), loss of range in
41 (5.5%), aspiration in 1 (0.1%), other changes in voice quality
(pitch change, loss of volume, cracking, tickling, or itching in
the throat, breathiness, voice breaks, tight or strangled speech,
and dysarthria) in 61 (8.1%), odynophagia in 1 (0.1%), and no
voice complaint in 12 (1.6%). The patients who did not have

TABLE 1.
History of Laryngeal Surgery
Surgery

Total

Percentage

Type I thyroplasty
Type III thyroplasty
Direct laryngoscopy

8
1
6

1.1
0.1
0.8

True vocal fold injection


Teflon
Fat, collagen, or gelfoam
Botox (Allergen, INine, CA)
Steroid
More than one type of injection
materials

8
4
2
1
8

1.1
0.5
0.2
0.1
1.1

8
43

1.1
5.7

1
6

0.1
0.3

True vocal fold surgery


Cupped forceps biopsy
Micro direct
Laryngoscopy and excision of mass
Arytenoid reduction
More than one type of surgery
were performed

229
a voice complaint were found to have a laryngeal movement abnormality on routine indirect mirror examination, which was
confirmed subsequently and defined further by strobovideolaryngoscopy.

RESULTS
Strobovideolaryngoscopic findings are summarized in Table 2.
Patients with a diagnosis of arytenoid dislocation also underwent laryngeal CT as well as arytenoid palpation in nearly all
cases. LEMG in these patients was normal or revealed mild
paresis insufficient to explain vocal fold immobility. LEMG
was helpful in these patients in establishing or confirming the
diagnosis of mechanical fixation, as reported previously.2629
Table 3 summarizes laryngeal nerve function as assessed by
strobovideolaryngoscopy and LEMG. Paresis was diagnosed
when movement was present but sluggish. Paralysis was diagnosed when no volitional movement could be observed. If the
vocal fold was immobile but appeared to be innervated
(absence of a jostle sign and presence of good tone and muscle
activation in the absence of motion), mechanical dysfunction
(such as arytenoid dislocation or cricoarytenoid joint arthrodesis) was diagnosed. Strobovideolaryngoscopy and LEMG
results agreed with regard to paralysis/paresis and side of abnormality in 493 of 689 patients (71.5%) with suspected paresis/
paralysis. Paresis or paralysis was confirmed on LEMG for
661 of 689 (95.9%) patients in whom paresis had been suspected on stroboscopy and in 14 of 62 (22.5%) patients in
whom stroboscopy had not suggested paresis but who had
been referred for LEMG because of uncertainty about the etiology of their voice complaints (commonly fatigue) after laryngological examination. LEMG was normal bilaterally (all 4
nerves) in 28 of 689 (4.0%) patients who had been suspected
of having paresis based on stroboscopic findings and in 48 of
62 (77.4%) patients in whom normal LEMG had been expected
based on stroboscopy.
Thus, if we assume that LEMG is the gold standard, then
clinical examination by dynamic voice assessment and strobovideolaryngoscopy has a sensitivity of 97.93%, specificity of
63.15%, positive predictive value of 95.94%, negative predictive value of 77.42%, and test efficiency of 94.41%. Alternatively, if we define endoscopic evaluation as the gold
standard, LEMG has a sensitivity of 95.9% and a specificity
of 77.4%. We accept LEMG as the gold standard for patients
with suspected motion abnormalities although there are no
evidence-based data proving this to be the correct assumption.
Two hundred eighteen of the 751 patients studied (29%) had
fluctuating motion asymmetries described on strobovideolaryngoscopy. One hundred ninety of the 218 patients (87%) of
those with fluctuating motion asymmetries (25.3% of the total
study population) were found to have bilateral paresis/paralysis. In subjects found electromyographically to have bilateral
paresis, fluctuation was identified during strobovideolaryngoscopy in 108 (49.3%) and fluctuation was seen endoscopically
in 104 (47.5%) patients with unilateral paresis or paralysis on
LEMG. Of these, 69 (31.5%) had unilateral left paresis and
35 (16%) had unilateral right paresis. Interestingly, fluctuating

230

Journal of Voice, Vol. 24, No. 2, 2010

TABLE 2.
Other Strobovideolaryngoscopic Findings in Patients
with Evidence of Paresis or Paralysis

Finding
Arytenoid dislocation total
Left
Right
Bilateral
Bowing of vocal fold
Cricoarytenoid joint
fixationtotal
Left
Right
Bilateral
Cysttotal
Unilateral cyst
With reactive contralateral mass
Unilateral left
Unilateral right
Bilateral
Dysphonia plica ventricularis
Functional dysphonia
Granuloma
Laryngeal cancer
Laryngeal papilloma
Laryngopharyngeal
refluxtotal
Mild
Moderate
Severe
No specific severity
Leukoplakia or erythroplakia
Muscle tension dysphonia
Previous hemorrhagetotal
Left
Right
Bilateral
Pseudocysttotal
Left
Right
Bilateral
Pseudosulcustotal
Left
Right
Bilateral
Reinkes edema
Spasmodic dysphonia
Sulcus vocalistotal
Left
Right
Bilateral
Vocal fold edema
Vocal fold hemorrhagetotal
Left
Right
Bilateral

Number of
Patients Percentage
(n 751) of Total (%)
21
13
6
2
23
8
3
2
3
97
63
16
5
13
12
16
16
1
4
587
38
6
38
505
7
517
49
28
14
7
17
7
6
4
21
2
1
18
71
44
129
30
26
73
17
31
14
14
3

2.8

3.1
1.1

12.9

1.6
2.1
2.1
0.1
0.5
78.2

0.9
68.8
6.5

2.2

2.8

9.5
5.9
17.2

2.3
4.2

(Continued )

TABLE 2
(Continued )

Finding
Vocal fold masstotal
Left
Right
Bilateral
Vocal fold noduletotal
Left
Right
Bilateral
Vocal fold polyptotal
with reactive
contralateral mass
Unilateral left
Unilateral right
Bilateral
Vocal fold scartotal
Left
Right
Bilateral
Vocal fold teartotal
Left
Right
Bilateral
Vocal tremor

Number of
Patients Percentage
(n 751) of Total (%)
147
42
28
77
8
0
1
7
24
16
4
2
2
150
48
36
66
6
3
1
2
22

19.6

3.2

20

0.8

2.9

asymmetry was also identified during stroboscopy in 7 (3.2%)


patients with normal LEMG. These patients had MTD, and
the appearance of fluctuating asymmetries of motion resolved
after voice therapy as assessed by follow-up strobovideolaryngoscopy. Repetitive stimulation studies of the accessory
nerve (cranial nerve XI) were normal in 722 (96.1%) subjects,
abnormal in 16 (2.1%), and not performed for 13 (1.7%).
Tensilon testing was performed in 178 patients with fluctuating
motion asymmetries during stroboscopy. Tensilon test was normal in 140 (78.6% of the those tested) patients and abnormal in
38 (21.4%).
Follow-up LEMG studies are not obtained routinely so long
as findings on strobovideolaryngoscopy are improved or stable
and patients report no new complaints suspicious for change in
neuromuscular function. Occasionally, follow-up LEMGs are
obtained to confirm electrical findings that seem to be at substantial variance with clinical impressions or in patients who
do not improve clinically as anticipated after treatment. No
follow-up LEMG was obtained for 676 (90%) patients. Followup studies were performed at intervals ranging from 1 month
to 101 months (mean 19.7% months, SD 20.75) in 67
(9.05%) patients. One returned to normal electromyographically, 2 improved, 12 showed worsened paresis, and 52 revealed
no change from the prior LEMG.
Analysis of medical history produced information with regard to a history of cold sores. Cold sores are caused

Robert T. Sataloff, et al

TABLE 3.
Laryngeal Nerve Function
Nerve

231

Laryngeal Electromyography

Stroboscopy (%)

LEMG

Right recurrent laryngeal nerve


Normal
647 (86.2)
Paresis
73 (9.7)
Paralysis
31 (4.1)

658 (87.6)
84 (10.9)
11 (1.5)

Right superior laryngeal nerve


Normal
277 (36.9)
Paresis
463 (61.7)
Paralysis
11 (1.5)

286 (38.1)
458 (61)
7 (0.9)

Left recurrent laryngeal nerve


Normal
645 (85.9)
Paresis
70 (9.3)
Paralysis
36 (4.8)

655 (87.2)
81 (10.8)
15 (2)

Left superior laryngeal nerve


Normal
352 (46.9)
Paresis
382 (50.9)
Paralysis
17 (2.3)

409 (54.5)
337 (44.8)
5 (0.7)

Overall interpretation of findings


Paresis
689
Normal
62

675
76

commonly by the herpes simplex virus, which has been suspected as a frequent cause of neuropathy including superior laryngeal nerve paresis. Of the patients with LEMG-documented
paresis for whom information about cold cores was available,
557 had no history of cold sores and only 91 (14%) did. In those
with normal EMG, 52 had no history of cold sores and 15
(22.3%) had had cold sores. Information on cold sores was
not available for 36 patients. Non-parametric statistical analysis
was performed using the significance of the difference between
2 independent proportions, which showed Z 1.83 (no statistical significance), and a 2-tailed test yielded a P value of 0.06
(not significant). We had expected a higher percentage of
patients with cold sores in the group with documented paresis.
Virtually all patients were treated with voice therapy, and
some also underwent surgery. Table 4 lists the percentage of
patients (professional and nonprofessional voice users) who underwent surgical and nonsurgical therapy. Professional and
nonprofessional voice users were analyzed statistically using
the same methodology listed above for analysis of the cold
sores. For paresis, there was no significant difference in the incidence of surgery between professionals and nonprofessionals
(Z 1.4, P 0.16). There was also no statistically significant
difference in the percentage of professional and nonprofessional voice users undergoing surgery in the group with normal
recruitment (Z 0.58, P 0.56). Tables 57 summarize the
status of laryngeal nerve abnormalities in the group that
required surgery and in patients who did not. These data were
analyzed using the significance of the difference between 2 proportions (non-parametric and appropriate for proportional
data). Statistical analyses are summarized in Table 10. These interesting data show that there is no significant difference in the
number of subjects with normal recruitment in the surgical and

TABLE 4.
Professional and Nonprofessional Voice Patients:
Surgical and Nonsurgical Treatment
Professional Nonprofessional
(%)
(%)
Paresis
No surgery
Surgery
Normal
recruitment
No surgery
Surgery

227 (86.3)
177 (77.97)
50 (22.03)
36 (13.7)

448 (91.8)
325 (72.5)
123 (27.5)
40 (8.2)

29 (80.5)
7 (19.5)

30 (75)
10 (25)

Total

263 (100)

488 (100)

Total
(%)
675 (89.8)

76 (10.2)

751 (100)

nonsurgical groups. Patients with mild paresis are more likely


to be treated successfully (as defined below) nonsurgically. Patients with moderate paresis are about equally likely to be satisfied with voice therapy alone or to require surgery. However,
patients with severe paresis or paralysis are much more likely to
require surgery. The positive predictive value for the degree of
paresis is 96.8%, and the negative predictive value is 46.5%. It
is important to note that LEMG findings were not used to make
surgical decisions. Rather, patients received voice therapy until
optimal improvement had been achieved (plateau in improvement observed by the patient, voice pathologist, and laryngologist), at which time they elected either no further treatment,
intermittent supportive voice therapy, or surgery if they were
not satisfied with their phonatory performance. The choice of
such a subjective criterion for outcome assessment may prove
controversial, but it was made after extensive consideration of
alternatives. Although objective voice measures or voice handicap index (VHI) scores would have provided more elegant,
quantitative data, they do not reflect accurately the clinical decision-making process. Regardless of those measures, clinical
decisions are based on subjective patient satisfaction and on
a complex decision-making process that includes the patient
and all of the professionals on the voice team. Although it

TABLE 5.
EMG Findings in the Surgery Group and Nonsurgery
Group by Individual Laryngeal Nerve Function
EMG Finding

Surgery
Group (%)

Nonsurgery
Group (%)

All nerves normal


Unilateral SLN
Unilateral RLN
Bilateral SLN
Bilateral RLN
Unilateral SLN, RLN
Unilateral SLN, bilateral RLN
Bilateral SLN, unilateral RLN
All 4 nerves paretic
Total

17 (8.9)
80 (42.1)
10 (5.3)
39 (20.5)
1 (0.5)
29 (15.3)
3 (1.3)
7 (3.7)
4 (2.1)
190 (100)

6 (4.24)
72 (61)
2 (1.7)
32 (27.1)
0
4 (3.4)
0
2 (1.7)
0
118 (100)

SLN, superior laryngeal nerve; RLN, recurrent laryngeal nerve.

232

Journal of Voice, Vol. 24, No. 2, 2010

TABLE 6.
EMG Findings in the Surgery Group and Nonsurgery
Group, by Number of Paretic Nerves

TABLE 8.
Statistical Analysis

EMG Paresis
Present in:

Normal
Mild paresis
Moderate paresis
Severe paresis
and paralysis

1 nerve
2 nerves
3 nerves
4 nerves
Total

Surgery
Group (%)

Nonsurgery
Group (%)

90 (52.02)
69 (39.9)
10 (5.78)
4 (2.3)

74 (66.1)
36 (32.1)
2 (1.8)
0

173 (100)

112 (100)

cannot be quantified elegantly, the patients decision and selfassessment are truly the ultimate outcome criteria used in clinical practice. If patients are satisfied with voice function after
therapy, then we treat them with therapy alone. If they are so
dissatisfied with voice function once they have plateaued in
therapy that they are willing to accept the risks of surgery,
and if there is a reasonable chance of improving their dysphonia
through surgical intervention, then we operate upon them.
Hence, despite the lack of elegant quantification, we felt it
would be most useful to base this report on the outcomes information on which we actually base our clinical decisions. Tables
8, 9, 10, and 11 summarize the surgical interventions performed
for this patient cohort.
DISCUSSION
LEMG has become a common adjunct in the care of voice patients. The procedure may be performed by a neurologist, physiatrist, or laryngologist skilled in electrodiagnostic medicine.
The most appropriate electrode choice (monopolar, bipolar,
concentric, hooked wire, or single fiber) varies depending on
the clinical information desired. We use monopolar electrodes
routinely to obtain a global assessment of neuromuscular function of individual laryngeal muscles. Under specific circumstances, we also use different types of electrodes to obtain
other kinds of information (such as single fiber recordings in
patients with suspected neuromuscular junction dysfunction
and bipolar or concentric electrodes when information on
more discrete areas of a muscle is desired).
Although many LEMG teams perform studies with the laryngologist and neurologist present simultaneously, we have
found it useful to have our neurologist perform these studies

Recruitment

Surgical Nonsurgical
17/190
117/190
25/190
31/190

5/118
102/118
9/118
1/118

1.56
4.68
1.50
8.838

.059
.0001
.066
.0001

alone, blinded to the clinical laryngoscopic findings. This


arrangement probably accounts for the fact that nearly 30%
of patients studied show a difference in the presence or side
of suspected paresis (based on stroboscopy). For example, it
is not rare for us to suspect a paresis on the right, for example,
and have LEMG reveal normal right function with left paresis.
Commonly, but not always, in such patients, after muscle tension dysphonia (MTD) has been eliminated through voice therapy, the left paresis becomes obvious clinically and corresponds
with the original LEMG finding. Such information is particularly valuable if a patient eventually needs surgical medialization, assisting in determination of which side should be
treated primarily. We consider this information one of the key
findings in this study. It highlights the shortcoming of relying
upon visual evaluation (endoscopy) alone to diagnose movement
disorders. Because similar findings have not been reported from
other centers, this observation also raises a question of whether
the presence during LEMG procedure of the laryngologist who
has recently performed stroboscopy may introduce bias that
affects LEMG interpretation. Further study may be warranted.
Readers will note that we have identified many more superior
laryngeal nerve problems (873) than recurrent laryngeal nerve
abnormalities (210). We have reported previously on superior
laryngeal nerve paresis.3033 This diagnosis is probably common because of the small nerve going to one muscle and the absence of any significant accessory innervation or efficiently
compensatory muscle. The diagnosis may be missed if vocal
dynamics assessment is not carried out long enough to fatigue
the patient. Commonly, asymmetries of motion are not noted
until after 30 to 60 seconds of phonation. In addition, there is
TABLE 9.
Vocal Fold Injection Procedures
Number Percentage

TABLE 7.
Comparison of Severity of Paresis in Surgical and
Nonsurgical Group
Severity of Paresis

Surgery
Group (%)

Nonsurgery
Group (%)

Normal recruitment
Mild paresis
Moderate paresis
Severe
Paralysis
Total

17 (8.9)
117 (61.6)
25 (13.2)
24 (12.6)
7 (3.7)
190 (100)

5 (5.1)
102 (86.4)
9 (7.6)
1 (0.8)
0
118 (100)

Lipoinjection
Collagen
Gelfoam
Teflon
Botox (under local anesthesia)*
Botox (under general anesthesia)*
Radiesse
Steroid
Cymetra
None

34
11
2
0
31
2
8
4
3
656

4.5
1.4
0.3
0
4.1
0.3
1
0.5
0.4
87.4

* Botulinum toxin was used to treat dystonia, synkinesis, or for chemical


tenotomy after arytenoid cartilage reduction.

Robert T. Sataloff, et al

Laryngeal Electromyography

TABLE 10.
Vocal Fold and Other Laryngeal Surgery
Number Percentage
MDL with excision of mass
Arytenoidectomy
Arytenoid reduction
Selective recurrent laryngeal
nerve section
Laryngofissure and repair fracture
Reduction of vocal
process avulsion
None

94
2
5
1

12.5
0.3
0.7
0.1

1
1

0.1
0.1

647

86.2

a misconception that the only observable findings are decrease


in longitudinal tension or laryngeal tilt toward the side of the lesion at high pitches. However, the most common manifestation
is sluggishness of abduction and adduction during rapidly repeated phonatory tasks. Even mild paresis can affect projection
and other aspects of vocal efficiency, leading to compensatory
MTD and sometimes to structural injury. LEMG is extremely
helpful in confirming or refuting this diagnosis so that appropriate therapy can be used.
We were also interested to note LEMG findings in the 62 patients who complained of dysphonia but in whom strobovideolaryngoscopy and assessment of laryngeal dynamics revealed
normal findings. LEMG detected paresis in 22.5% of these patients, identifying neuromuscular pathology that had been
missed during visual assessment. The most common complaint
in this group of patients was voice fatigue. This complaint was
consistent with the paresis diagnosed on LEMG, and the patients improved with voice therapy targeted toward ameliorating the effects of paresis.
It should also be noted that 21 patients with motion abnormalities who were referred for LEMG and who were found to
have normal or nearly normal neuromuscular function had
vocal fold immobility due to cricoarytenoid joint arthrodesis
or subluxation/dislocation. These patients and their LEMG
findings have been reported separately.29 Cricothyroid joint
dysfunction can mimic recurrent laryngeal nerve paresis. The
typical scenario in the more common cricoarytenoid joint impairment involves a patient who has been subjected to laryngeal
trauma (surgical or external) and has an essentially immobile
TABLE 11.
Number of Laryngeal Surgical Procedures per Patient
Percentage of Percentage
Total Subjects of Surgery
Number in the Study
Patients
No operation
Operative case
1 procedure only
23 procedures
45 procedures
More than 5
procedures

561
190
114
53
12
11

74.7
25.3
15.2
7.1
1.6
1.5

0
100
60
27.9
6.3
5.8

233
vocal fold. As discussed in our previous publications,2629 a normal or mildly decreased recruitment pattern rules out vocal fold
paralysis as the cause of immobility and, in conjunction with
computed tomography and endoscopy (usually including palpation), establishes a diagnosis of mechanical fixation.
Fluctuating paresis (initially 1 vocal fold appears sluggish;
then it appears to move well, and the other vocal fold appears
sluggish) was described by the author (R.T.S) as a sign of laryngeal myasthenia gravis34; and it may also be caused by bilateral
paresis, unilateral paresis with hyperfunctional compensation,
and occasionally by MTD. LEMG is invaluable in differentiating among these possible diagnoses. Establishing an accurate
diagnosis is essential because treatment varies depending on
etiology. Myasthenia gravis is treated with medications; and superior laryngeal nerve paresis is treated with voice therapy techniques that differ from those used for recurrent laryngeal nerve
paresis or MTD with normal innervation.
The authors had suspected that there might be a difference in
success and percentage of patients electing surgery comparing professional voice users and nonprofessionals. There was
no significant difference (not even a trend). It appears that both
groups show a similar desire to achieve optimal voice, although
their definitions of optimal may vary and were not investigated in this study. We believe that this finding is intriguing
and warrants further investigation.
This report does not address the accuracy of LEMG in diagnosing diseases affecting the neuromuscular junction, although
we have found it valuable for that purpose, as reported previously.35 We also have not addressed specifically in this data
analysis several other proposed uses for LEMG. However, we
have found LEMG valuable for detecting psychogenic dysphonia or malingering. Like other authors, we use LEMG to detect
dystonic neuromuscular patterns and other signs of dystonia,
such as delays greater than 200 ms between the onset of the
electrical signal and audible phonation,36 to identify tremor,
and to diagnose other conditions that may be confused with laryngeal dystonia (including psychogenic dystonia). In addition,
LEMG has been valuable in identifying the presence or absence
of cricothyroid muscle involvement in patients with abductor
spasmodic dysphonia, many of whom benefit from botulinum
toxin treatment to the cricothyroid muscle in addition to posterior cricoarytenoid muscle injection. We also agree with many
other laryngologists that LEMG is valuable for needle guidance
for botulinum toxin injection. This report also does not address
data on detection of systemic neuropathic and myopathic disorders involving the larynx but our experience suggests that the
response of laryngeal skeletal muscles to upper motor neuron
disorders, lower motor neuron disorders, myopathic disorders,
and other neurologic abnormalities does not differ from that
of other skeletal muscles; and LEMG has led us to such diagnoses as amyotrophic lateral sclerosis, myasthenia gravis, Parkinsons disease, and postpolio syndrome.

CONCLUSION
Our experience and the data reported in this study suggest that
LEMG provides useful prognostic information regarding the

234
likelihood of recovery of satisfactory phonatory function without surgery, following vocal fold paresis or paralysis. Patients
with mild paresis are less likely to require laryngeal surgery
than those with severely reduced recruitment response. Laryngeal EMG also provides valuable diagnostic information for
differentiating vocal fold paresis or paralysis from mechanical
fixation of the cricoarytenoid joint. Our data indicate that visual
assessment alone is inadequate to diagnose neuromuscular
dysfunction in the larynx and that diagnoses based on vocal dynamics assessment and strobovideolaryngoscopy are wrong in
nearly one-third of cases, based on LEMG results. LEMG has
also proven valuable in diagnosing neuromuscular dysfunction
in some dysphonic patients with no obvious abnormalities during strobovideolaryngoscopy. Research to confirm or refute the
value of these and other uses of LEMG should be encouraged.

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