Laryngeal Electroglottography as a Predictor of

Laryngeal Electromyography
*Russell W. Mayes, ,{Cristina Jackson-Menaldi, ,Philippe H. DeJonckere, kCheryl A. Moyer,
and {,**AdamD. Rubin, *Pontiac, Michigan, yDetroit, Michigan, {St. Clair Shores, Michigan, zUtrecht, The Netherlands, xLeuven, Belgium,
**kAnn Arbor, Michigan
Summary. We evaluate a group of patients who have mobile vocal folds, but have exible laryngeal examinations
suspicious for mild vocal fold paresis. The purpose of this retrospective study is to evaluate if electroglottography
(EGG) can predict the probability of having an abnormal laryngeal electromyography (LEMG). Charts of patients eval-
uated and suspected of having mild vocal fold paresis between August 1, 2004 and March 30, 2006 were reviewed. We
compared average EGG contact quotients (CQs), average absolute difference of recorded CQ from normal
(jCQ 50%j), and EGG waveforms between patients with normal and abnormal LEMG. Waveforms were evaluated
in blinded fashion. Statistical analysis was performed using chi square and t test analyses. One hundred and sixteen pa-
tients received both exible laryngoscopy and LEMG as part of their evaluation. Forty-eight patients (41%) had con-
rmed paresis by LEMG and 68 patients (59%) had normal LEMGs. Only 9.1% of patients with a normal EGG
waveform had an abnormal LEMG. In contrast, 40.4% of patients with an abnormal EGG waveform had abnormal
LEMGs. The negative predictive value of a normal EGG waveform for an abnormal LEMG was 90.9%. No signicant
differences were identied between patients with normal versus abnormal LEMG in terms of average CQ (47.8% vs
46.4%) or jCQ 50%j (6.2 vs 5.6). Patients with a normal EGG waveform are unlikely to have an abnormal LEMG.
Key Words: Laryngeal electroglottographyLaryngeal electromyographyVocal cord paresis.
INTRODUCTION
Vocal fold paresis may be caused by injury to the superior laryn-
geal nerve, recurrent laryngeal nerve, or both. Patients with
a unilateral vocal fold paralysis or severe paresis typically pres-
ent with a breathy voice resulting from a failure of the vocal
folds to approximate completely during phonation. Identica-
tion of severe paresis or paralysis is often straightforward and
can be made on most routine laryngeal examinations. Typically,
there is little to no movement of the affected side and a large
glottic gap with adduction. Mild vocal fold paresis may exist
in patients with voice complaints and present with more subtle
examination ndings, such as vocal fold lag.
1,2
Vocal fold pare-
sis may contribute to the development of vocal pathology, by
leading to excessive compensatory muscle tension and hyper-
function.
1,3,4
Laryngeal electromyography (LEMG) is currently the best
objective study to conrm the presence of laryngeal nerve in-
jury.
5,6
Its use in the evaluation and treatment of voice disorders
is controversial. Although most would agree on its usefulness in
distinguishing a vocal fold paralysis from a structural cause of
vocal fold immobility, such as cricoarytenoid joint ankylosis
or arytenoid cartilage dislocation,
7
there are no standard
indications for obtaining an LEMG. Moreover, the test can be
uncomfortable for patients and may add considerable expense
to their health care.
Electroglottography (EGG) is a commonly used method to
objectively evaluate vocal fold contact, by monitoring changes
in impedance across the glottis during the oscillatory cycle.
8
EGGmay be interpreted with calculations reecting the contact
phase of the vibratory cycle, such as the contact quotient (CQ),
or by evaluating the geometry of the waveform itself.
810
Titze
developed mathematical models to describe EGGwaveforms.
11
Although not every EGGwaveformexactly ts into his schema,
the waveform often can be explained by the underlying vocal
pathology.
9,12,13
We predicted that mild vocal fold paresis should affect glottic
contact and therefore EGG. The purpose of this study was to de-
termine if EGG can predict the probability of having an abnor-
mal LEMG, and therefore, be a useful screening test to help
determine if LEMG is warranted.
MATERIALS AND METHODS
This is a retrospective review of patients evaluated for dyspho-
nia at a private voice center between August 1, 2004 and March
30, 2006. All the patients included were evaluated by the same
laryngologist (ADR) and voice pathologist (CJ-M). Each was
suspected of having vocal fold lag on exible laryngoscopic ex-
amination.
1
All the patients included in the study underwent
LEMG. Patients were excluded from the study if 1) they had
a vocal fold paralysis or severe paresis, 2) they had a large
mass preventing glottic closure, or 3) they did not have an EGG.
All LEMGs were performed by the same neurologist who is
board certied in electromyography. A monopolar electrode is
used to test the cricothyroid and vocalis muscles. Interpretation
of the LEMG includes commentary on which nerve(s) is (are)
involved, presence of spontaneous activity and brillation po-
tentials, and the morphology of the action potentials. No effort
is made to quantify degree of nerve injury.
6,1416
Accepted for publication March 9, 2007.
From the *POH Medical Center, Pontiac, Michigan, USA; ySchool of Medicine, Wayne
State University, Detroit, Michigan, USA; zGraduate School for Speech, Hearing & Swal-
lowing Sciences, Utrecht University, Utrecht, The Netherlands; xCatholic University of
Leuven, Leuven, Belgium; {Lakeshore Professional Voice Center, Lakeshore ENT, St.
Clair Shores, Michigan, USA;
k
School of Medicine, University of Michigan, Ann Arbor,
Michigan, USA; and the **Department of Otolaryngology, Head and Neck Surgery, Uni-
versity of Michigan Medical School, Ann Arbor, Michigan, USA.
Address correspondence and reprint requests to Adam D. Rubin, MD, Lakeshore Profes-
sional Voice Center, Lakeshore ENT, 21000 E. 12 Mile Road, Suite 111, St. Clair Shores,
MI 48081. E-mail: rubinad@sbcglobal.net
Journal of Voice, Vol. 22, No. 6, pp. 756-759
0892-1997/$34.00
2008 The Voice Foundation
doi:10.1016/j.jvoice.2007.03.005
EGGwas performed and CQwas determined for each patient
as part of the initial objective voice evaluation by one voice pa-
thologist (CJ-M). CJ-M was unaware of the results of the ex-
ible laryngoscopic examination at the time of the initial
objective voice evaluation. The EGG is performed by placing
supercial electrodes on both sides of the thyroid cartilage. A
current is then passed through the larynx. Subjects are in-
structed to vocalize and sustain the vowel /a/ at the pitch of
the speaking voice in a normal speaking volume. The EGG sig-
nal was recorded simultaneously with Laryngograph Kay Ele-
metrics using software version 2.7.0 Model 5138 Real Time
EGG Analysis with two channels. For reference purposes, the
acoustic signal was recorded at a sampling rate of 48,000 Hz.
Each sample has a minimumrecording of 3 seconds. The events
of closure and opening were determined manually by placing
vertical lines at the points of initial and nal contact. CQ is
then calculated by the computer program. A CQ of 50 1% is
considered normal.
9,1619
The absolute difference between cal-
culated CQ and 50% was recorded (jCQ 50%j).
EGG waveforms for each patient were evaluated by a single
voice scientist (PHD) with expertise in EGG. Waveforms were
classied as normal or abnormal. PHD was blinded from the -
beroptic and LEMGndings of each patient, as well as fromthe
purpose of the investigation.
Using numeric identiers for each patient, all data were en-
tered into an Excel spreadsheet (Microsoft Inc., Redmond,
WA) and cleaned. Data were imported into SPSS for Windows
(SPSS Inc., Chicago, IL) for analysis. Descriptive statistics and
overall frequencies were calculated. Means were compared us-
ing t tests, and categorical data were compared using chi square.
RESULTS
One hundred and sixteen patients suspected of having vocal
fold paresis underwent LEMG as part of their evaluation.
Forty-eight patients (41%) had conrmed paresis by LEMG
and 68 patients (59%) had normal LEMGs. Fifty-four patients
met at least one exclusion criteria listed above. In the included
subjects (n 62), 11 patients had normal EGG waveforms.
Only one of these subjects (9.1%) had an abnormal LEMG.
Of the 51 patients with abnormal EGG waveforms, 21
(40.4%) had abnormal LEMGs. This difference is statistically
signicant with P 0.044 (Figure 1). The negative predictive
value, sensitivity, and false negative rates of EGG in terms of
LEMG results were 90.9%, 95%, and 1.6%, respectively. The
positive predictive value, specicity, and false positive rates
were 41.2%, 25%, and 48.4% (Table 1).
Average CQ and jCQ 50%j among subjects with normal
LEMGs (n 40) were 47.8% and 6.2, respectively. These
values among subjects with abnormal LEMGs (n 22) were
46.4%and 5.6, respectively. There was no signicant difference
(P 0.435 and P 0.567).
DISCUSSION
This study suggests that LEMGis unlikely to be abnormal when
the shape of the EGG waveformis normal. The negative predic-
tive value of a normal EGG waveform was greater than 90%,
whereas the false negative rate was only 1.6%. Thus, EGG
can be a useful screening test to facilitate the laryngologists de-
cision to obtain an LEMG. EGG is less invasive, easier to per-
form, and less expensive than LEMG.
Vocal fold lag is a common nding in patients with a mild vo-
cal fold paresis. However, this nding can also be seen in nor-
mal subjects.
11
In cases where vocal fold lag is identied, but
clinical suspicion of a paresis is not particularly high, a normal
EGG waveform would suggest that the LEMGis likely going to
be of lowyield. On the other hand, an abnormal EGGwaveform
is not specic for a paresis (specicity 41.2%, false positive
rate 48.4%). This is not surprising, given many things can af-
fect glottal contact including masses, scar, and poor technique.
However, with an abnormal EGG waveform, there is a signi-
cantly greater chance of nding an abnormality on LEMG.
EGG reects the changes in overall conductance between
two electrodes placed on either side of the larynx.
6
The result-
ing waveform represents variations in the area of contact be-
tween the vocal folds.
8
The characteristics of a normal wave
in modal register at comfortable pitch and intensity are 1)
a well-dened point of rst contact, 2) a steep slope for the in-
creasing contact surface, steeper than for the opening phase, 3)
a knee in the opening phase in males, 4) a closed part which
is less important than the open part (about 1/32/3), 5) a sta-
ble pattern from cycle to cycle on a sustained vowel, and 6) an
increase of the closed part with louder phonation (Figures 2
0
5
10
15
20
25
30
35
Normal EGG
Waveform
Abnormal EGG
Waveform
Normal LEMG
Abnormal LEMG
N
u
m
b
e
r

o
f

P
a
t
i
e
n
t
s
FIGURE 1. Comparison of EGG waveform and LEMG results.
TABLE 1.
Predictive Values of Normal EGG Waveform with
Evidence of Paresis by LEMG
%
Negative predictive value 90.1
Positive predictive value 41.2
Sensitivity 95
Specicity 25
False negative rate 1.6
False positive rate 48.4
Russell W. Mayes, et al EGG as Predictor of LEMG 757
and 3).
8
Deviant EGGs are characterized by patterns resem-
bling sinus waves that may have a superimposed short (contact)
peak. Also, deviance may be characterized by pattern deteriora-
tion and/or increased perturbation (Figures 4 and 5). Although
there were a higher percentage of abnormal EGG waveforms in
patients with abnormal LEMGs, CQ and jCQ 50%j values
did not differ signicantly between the two groups. This sug-
gests that the percentage of time during the contact phase of
the oscillatory cycle did not differ signicantly. Therefore,
these values are not useful screening tools.
A valid criticism of the results of this study is that only the
EGG waveform, not any quantiable data, was statistically
able to predict an abnormal LEMG. And, evaluation of the
EGG waveform is admittedly subjective based on the expertise
of the voice scientist. Thus, its usefulness as a screening tool to
determine which patients may benet from an LEMG may
be limited based on the experience and comfort level of the
scientist evaluating the EGG. This being said, our research is
a rst attempt at trying to evaluate the usefulness of EGG
as a clinical screening tool. As EGG continues to be used, it
would make sense to establish a standardized protocol for the
interpretation of EGG waveforms that makes evaluating EGG
independent of the rater.
The usefulness of LEMG in the evaluation and treatment of
voice disorders is still controversial and will only be determined
by randomized, prospective studies with good outcome mea-
sures. This study demonstrates that the probability of having
an abnormal LEMG is signicantly lower when the EGG wave-
form is normal. Unless clinical suspicion is high, LEMG likely
is not useful in these cases.
CONCLUSIONS
Patients with normal EGG waveforms are unlikely to have an
abnormal LEMG. EGG may be used as a screening test in
FIGURE 2. Schematic of a normal EGG.
FIGURE 3. Example of a normal EGG.
FIGURE 4. Example of an abnormal EGG.
Journal of Voice, Vol. 22, No. 6, 2008 758
patients with examination ndings suggestive of subtle paresis
to determine if proceeding with LEMG is likely to be of high
yield.
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FIGURE 5. Example of an abnormal EGG.
Russell W. Mayes, et al EGG as Predictor of LEMG 759