Repeatability of assessment
Consistency of re-examination affects clinical outcome and management
decisions. When the 5-point scale is used, it is clear that the
intra-rater consistency is lower, compared to the 3 point score.
The diagnosis of vocal cord paresis is felt to be more challenging than
vocal cord paralysis12. This is highlighted in this
study with the low inter rater specific agreement for the scores 1, 2
and 3 in the 5 point scale, and score 1 in the 3 point scale (Table 3),
which demonstrates that clinicians disagree with what they are seeing
when vocal cord paresis is present. Vocal cord movement is a continuum
with paresis not as well recognised or studied as paralysis. Wu et al
highlighted that in laryngology practice in North America, the most
common diagnostic tool for diagnosing paresis was stroboscopy, not
flexible nasendoscopy. Simpson et al reported that in a large series of
739 patients presenting to a tertiary laryngology service with a chief
complaint of dysphonia, of the 26.4% with paresis or paralysis on
stroboscopy, only 1.8% of the patients had LEMG confirmed vocal fold
paresis. In stark comparison Satalof et al demonstrated that in his
series of 689 patients with suspected paresis or paralysis, the LEMG
confirmed this diagnosis in 95.9% of the patients. This significant
variation between diagnosis and confirmation on LEMG highlights that we
are still not able to consistently differentiate between these
diagnoses. Although LEMG is the only way to confirm definitively that a
patient has a paralysis or paresis, it is not routinely performed in
clinical practice.