State-of-the-Art Techniques Are Tempting, but May Not Improve Care

TORONTO-While state-of-the-art care is appealing, standard care is often an equally effective choice for treatment of laryngological disorders. This was one of the key messages from a panel discussion on state-of-the-art versus standard care here at the meeting of the Eastern Section of the Triological Society.

The session was moderated by Peak Woo, MD, Professor of Otolaryngology at the Mount Sinai School of Medicine in New York, NY. He presented four cases that may be seen in a typical practice.

Assessing Immobile Vocal Cords

The first was of an 18-year-old female who had undergone total thyroidectomy for Graves disease and who had an immobile vocal fold and a primary complaint of voice problems. Diagnostic options include waiting to see what happens because the nerve appears to be intact, getting a laryngeal electromyography (EMG) performed, or referring the patient for voice therapy.

Dr. Woo said he opted for an EMG, which he considers to be somewhere between state-of-the-art and standard care. In this case, EMG readings showed no fibrillation potential and no complex discharges on the left thyroarytenoid. There was only 20% recruitment with variable motor units, with only a few of them polyphasic, he said. The question was what should be done next.

Generally, the panelists favored EMG, but use it to varying degrees.

I’m a laryngeal EMG enthusiast, I think it really does help and offers a slightly more refined level of care. But I’m not a zealot, said Lucian Sulica, MD, Assistant Professor of Otorhinolaryngology Director of Voice Disorders/Laryngology at Weill Medical College of Cornell University in New York City. While EMG is more state of the art, it’s not necessary for providing good care to this sort of patient, he noted.

EMG is useful as a negative predictor to get a feel of where the condition is headed. He added that voice testing and phonograms are useful, but one needs to be scholarly about tracking outcomes.

EMG is Predictive, but Utility Still Evolving

EMG has lead to a deeper understanding of what vocal fold paralysis is. One of the reasons I’m an EMG enthusiast, Dr. Sulica said, is because since we started EMG we understand that a lot of immobile vocal folds are not innervated vocal folds…giving us this new concept about what vocal fold paralysis is.

Ramon Franco, Jr., MD, Instructor in the Department of Otology and Laryngology and Acting Director of the Voice Center at Harvard Medical School in Boston, Mass., said that EMG can be predictive and provide something to show the patient. Yet, there are many issues related to the way it’s performed, how it’s interpreted. This is still in its infancy in terms of how we use it as a diagnostic tool, he said.

If you’re dealing with carcinoma in situ with questionable invasion, then it is reasonable to treat with PDL, do a brush biopsy and follow-up, or at least some histology follow-up. – Stanley Shapshay, MD