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Diagnostic Accuracy of Laryngeal Ultrasound for Evaluating Vocal Fold Movement Impairment in Children
Shawn Izadi1, Benjamin Zendejas1, Jay Meissner1, Ali Kamran1, Somala Mohammed1, Farokh Demehri1, Steven Staffa1, David Zurakowski1, Anne Hseu3, Michael Cunningham3, Sukgi Choi3, Carol Barnewolt2 1. Department of Surgery, Boston Children's Hospital, Boston, MA. 2. Department of Radiology, Boston Children's Hospital, Boston, MA. 3. Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA

Background: Vocal fold movement impairment (VFMI) secondary to recurrent laryngeal nerve (RLN) injury is a common source of morbidity after pediatric cervical, thoracic, and cardiac procedures. Flexible laryngoscopy (FL) is the gold standard to diagnose VFMI, yet it's invasive, poorly tolerated, risks possible clinical decompensation, and is an aerosol generating procedure. Laryngeal ultrasound (LUS) is a potential non-invasive alternative, but limited data exists in the pediatric surgical population regarding its efficacy. We aimed to investigate the diagnostic accuracy of LUS compared to FL in evaluating VFMI.

Methods: A prospective, single-center, single-blinded (rater) cohort study was undertaken on perioperative pediatric patients at risk for RLN injury. Patients underwent FL and LUS. Cohen's kappa was used to determine chance-corrected agreement.

Results: Between 2021 and 2023, 85 children were evaluated with a median (IQR) age of 10 (4, 42) months and weight of 7.5 (5.4, 13.4) kilograms. The prevalence of VFMI was 27.1%. Absolute agreement between evaluations was 98.8% (kappa 0.97, 95% CI:0.911.00, p<0.001). The sensitivity and specificity of LUS in detecting VFMI was 95.7% and 100%, yielding a positive predictive value (PPV) of 100% and negative predictive value (NPV) of 98.4% (95% CI:90-100%). Diagnostic accuracy was 98.8% (95% CI:93-100%).

Conclusion: LUS is a highly accurate modality in evaluating VFMI in children. While FL remains the gold standard for diagnosis, LUS offers a low-risk screening modality for children at risk for VFMI such that only those with an abnormal LUS or presence of clinical symptoms discordant with LUS findings should undergo FL.
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