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Original article
Cervical ultrasound for the evaluation of the vocal cords: A pilot study in an endocrine surgery unit
Ecografía cervical para la evaluación de las cuerdas vocales: estudio piloto en una unidad de cirugía endocrina
Luis Eduardo Pérez-Sáncheza,
Corresponding author
l.eduardopesan@gmail.com

Corresponding author.
, Eugenia Caballero-Rodrígueza, Rafael Orti-Rodrígueza, Ana Soto-Sáncheza, Miguel Ángel García-Bellob, Julio César Jordán-Balanzaa, Manuel Ángel Barrera-Gómeza
a Unidad de Cirugía Endocrina, Servicio de Cirugía General y Digestiva, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
b Departamento de Epidemiología Clínica y Bioestadística, Unidad de Investigación, Hospital Universitario Nuestra Señora de la Candelaria y Atención Primaria, Santa Cruz de Tenerife, Spain
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who may subsequently develop multiple types of physical and psychosocial sequelae&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but also for surgeons&#44; as they are a common cause of medico-legal claims&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Therefore&#44; assessment of VC function is nowadays necessary in patients in whom a total thyroidectomy is planned&#44; in those with previous cervical operations or with previous voice impairment&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Flexible laryngoscopy &#40;FL&#41; is currently considered the gold-standard for the assessment of VC function&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although widely available&#44; FL is an invasive procedure and&#44; at least in our setting&#44; requires evaluation by an ENT specialist&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In recent years&#44; cervical ultrasound &#40;CU&#41; has proven to be a promising tool in the assessment of VC function and has been used in some high-volume thyroid surgery centres with good results&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> Unlike FL&#44; CU is a non-invasive procedure performed in the same pre-surgical consultation that can be routinely performed by endocrine surgeons&#46; Although CU appears to be a promising technique in this field&#44; little has been studied on its implementation and use by thyroid surgeons&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of our study is to assess the reliability of CU once implemented in an endocrine surgery unit and performed by endocrine surgeons themselves&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">We conducted a prospective study between 1 January and 28 February 2021&#44; to assess the ability of 3 independent endocrine surgeons to assess laryngeal structures using CU with special emphasis on VC mobility&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Eighty-six subjects were included in the study consecutively and blinded to the surgeons who were to perform the ultrasound&#46; All participants were selected during surgical consultations not related to thyroid or cervical diseases&#46; Patients with previous cervical procedures &#40;surgery or radiotherapy&#41;&#44; known laryngeal conditions or any previously known voice disturbance were excluded&#46; Demographic variables such as height&#44; weight&#44; age and sex were recorded&#46; Informed consent was obtained from all participants&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Three independent endocrine surgeons&#44; with no previous ultrasound experience&#44; were trained by a CU specialist for 6 months&#46; Each surgeon performed more than 100 supervised procedures before starting the study&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The examination was performed in an isolated room where only one surgeon and one participant could be present&#46; The latter remained in the room until the 3 independent assessments were performed&#46; Each subject was not allowed to speak prior to the scan to avoid providing any additional information to the operator&#46; Each surgeon had a maximum of 180&#8201;s to perform the assessment&#44; but in case the scan ended earlier&#44; the surgeon had to remain in the room until the time was up&#46; Each participant was placed in a supine position on a stretcher with the neck in hyperextension and arms at the sides of the body&#46; A portable ultrasound system &#40;SonoSite M-Turbo Portable UltrasoundSystem&#44; Fujifilm&#44; USA&#41; with a 5&#8722;10&#8201;MHz linear transducer was used and placed transversely over the anterior surface of the neck&#46; The ultrasound technique used consisted of a systematic scan from the floor of the mouth to the second tracheal cartilage&#46; During the procedure&#44; the laryngeal structures at rest were initially assessed&#58; thyroid cartilage&#44; free edge of the VCs&#44; VC muscles and arytenoid cartilage&#46; Once all laryngeal structures were identified&#44; the mobility of the VCs was analysed by asking the subject to pronounce an &#47;i&#58;&#47; sound continuously in a soft voice and monitoring the vibration of the VCs in adduction&#46; The ultrasound patterns described by Singh et al&#46; in 2009<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> were followed&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">After evaluation of the laryngeal structures our findings were classified as visualisable&#44; when we were able to distinguish these structures bilaterally using CU&#44; and non-visualisable otherwise&#46; Specifically&#44; in the case of the evaluation of the VCs these were categorised as evaluable when in addition to being visualised &#40;free edge of the VCs&#41; we were able to determine their mobility&#59; those where movement could not be seen were classified as not evaluable &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; After the procedure each surgeon fills in a checklist per subject describing the laryngeal structures with the described details&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using R 4&#46;0 &#40;A language and environment for statistical computing&#46; R Foundation for Statistical Computing&#44; Vienna&#44; Austria&#46; URL <a href="https://www.R-project.org">https&#58;&#47;&#47;www&#46;R-project&#46;org</a>&#41;&#46; Continuous variables were expressed as median and interquartile range&#44; while qualitative variables were expressed as frequency and percentage&#46; To assess inter-operator agreement&#44; Fleiss&#8217; kappa analysis was performed&#44; calculated using the SPI function of the REL package &#40;RiccardoLoMartire &#91;2020&#93;&#46; rel&#58; Reliability coefficients&#46; R package version 1&#46;4&#46;2&#46; <a href="https://CRAN.R-project.org/package=rel">https&#58;&#47;&#47;CRAN&#46;R-project&#46;org&#47;package&#61;rel</a>&#41;&#46; Cochran&#39;s Q test was used to test for equality between several related samples on a dichotomous variable&#46; The Poisson regression model was used to determine the rate of any variable associated with the non-assessability of the technique&#46; The Kaplan&#8211;Meier and log-rank test was used to analyse the relationship between procedure time and assessability&#46; A p-value of less than &#46;05 was considered statistically significant&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">Our study included a sample of 86 consecutively selected participants in the general surgery practice&#46; Their ages ranged from 18 to 75 years&#44; with a mean age of 43 years&#46; The sex ratio showed an equal distribution and&#44; in terms of BMI&#44; our sample showed a prevalence of normal weight &#40;18&#46;5&#8722;24&#46;9&#8201;kg&#47;m2&#41; and overweight &#40;25&#8722;29&#46;9&#8201;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; subjects &#40;48&#37; and 36&#37;&#44; respectively&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">After assessment of the cervical region using CU&#44; the thyroid cartilage and VC muscle were the best visualised anatomical structures &#40;overall rate 98&#37; and 90&#37;&#44; respectively&#41;&#46; All 3 surgeons described a similar ratio&#46; The overall mean procedure time was 72&#8201;s&#44; with a maximum difference between operators of 6&#8201;s on average &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Although in this study CU was not compared to a gold-standard technique&#44; the concordance of assessability between the 3 operators was substantial&#44; with a Fleiss K-value of &#46;714&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows the degree of agreement between each pair of operators&#46; Likewise&#44; no statistically significant differences were found in the assessability index between the 3 surgeons &#40;p&#8201;&#61;&#8201;&#46;10&#41; after performing a Cochran&#8217;s Q test&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">After applying the Poisson regression model&#44; gender and age were identified as independent variables associated with the non-assessability of the technique&#46; The incidence rate in men was 2&#46;12 &#40;p&#8201;&#60;&#8201;&#46;001&#41; and in patients older than 60 years was 2&#46;37 &#40;p&#8201;&#60;&#8201;&#46;001&#41;&#46; BMI was not identified as a variable associated with the non-assessability of the technique&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the Kaplan Meier analysis illustrating the relationship between procedure time and the assessability of each patient&#44; between the 3 operators&#46; There is no difference in decision time according to the observer &#40;p&#8201;&#61;&#8201;&#46;60&#41;&#46; The mean procedure time is around 70&#8201;s with no major differences between surgeons&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Preoperative assessment of VCs is an essential requirement for good planning of thyroid surgery&#46; CU is an increasingly developed procedure and can be performed by surgeons as a bedside technique&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">VC paralysis&#44; although a relatively rare complication&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> is associated with increased morbidity affecting patients&#39; quality of life &#40;voice&#44; swallowing and airway&#41;&#46; This&#44; in turn&#44; has serious medico-legal implications and high costs for healthcare systems&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Therefore&#44; preoperative VC assessment is necessary&#44; especially in certain scenarios such as patients with voice abnormalities&#44; history of thoracic or cervical surgery&#44; known thyroid cancer or suspected&#47;confirmed lesion of the RLN or vagus nerve&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> Although FL is currently the gold-standard technique in the evaluation of these structures&#44; especially indicated in these scenarios&#44; CU has been developed as a preoperative screening method that can be implemented in all other cases&#44; being a less invasive technique and fundamentally more accessible to the endocrine surgeon in our environment&#46; For this reason&#44; authors such as Wong<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> have defended this technique with good results&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The appropriate study of VCs by CU is determined by certain intrinsic characteristics of the patients&#46; Gender and age must be considered&#44; as they are variables of particular relevance in the population in question&#44; since thyroid disease is more prevalent among younger women&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> The presence of a more protruding thyroid cartilage in males hinders the assessment of VCs&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a> In fact&#44; a more obtuse angulation of the anterior ala of the thyroid was associated with a better quality of laryngeal examination&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> This was also evident in our study&#44; where males were associated with a higher probability of non-assessment &#40;incidence ratio of 2&#46;12&#41;&#46; In terms of age&#44; the increased ossification of the thyroid cartilage with age hinders the passage of the ultrasound beam and&#44; therefore&#44; the images are poorer&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;17</span></a> It has also been observed in our analysis that older individuals have a poorer assessment compared to younger subjects&#46; In this regard&#44; patients over 60 years of age have a high risk of non-assessment in our study &#40;incidence ratio of 2&#46;37&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Excess body weight is a controversial feature due to its negative impact on ultrasound imaging&#46; While Kandil et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> oppose ultrasound as a substitute for FL&#44; especially in populations with higher BMI&#44; others such as Carneiro-Pla et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> support its use regardless of weight&#47;height ratio&#46; In our study&#44; 52&#37; of the individuals examined were overweight or obese&#44; despite which BMI was not associated with an increased risk of non-assessment&#44; as previously reported in other published series&#46; <a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> Although we did not measure neck diameter or the distance between the skin and the thyroid cartilage in our study&#44; these factors should be taken into account in future studies&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The duration of the technique is another relevant factor when implementing this technique&#46; Considering that it is a procedure that can be performed at the bedside&#44; and also considering the high number of patients seen in our healthcare system&#44; CU should not cause delays in the surgical consultation&#46; According to Wong<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> the average time required for an experienced operator to perform the technique is 30&#8201;s&#46; On the other hand&#44; Masood et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> have shown that the mean time for CU in expert hands is 1&#46;8&#8201;min&#46; In our study 70&#8201;s was the mean time between the 3 operators&#44; with no difference between them &#40;p&#8201;&#61;&#8201;&#46;60&#41;&#46; Furthermore&#44; most of the examinations were completed in less than 2&#8201;min&#44; as shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; In our opinion the timing of the procedure was relevant&#44; as a prolonged test time was associated with greater hesitancy in the assessment of VCs&#44; and thus a higher degree of non-assessable scans&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Preoperative ultrasound analysis of VCs has recently been investigated by many authors&#46; The high rate of VC assessment by CU would avoid invasive procedures and serves as a screening procedure prior to a more aggressive technique&#46; FL&#44; although the gold standard in laryngeal assessment&#44; could be reserved for selected cases in which CU cannot assess VC status &#40;e&#46;g&#46;&#44; males or elderly population&#41;&#44; remaining as a second-level examination&#44; or in cases at high risk of VC paralysis &#40;extracapsular thyroid carcinoma&#44; large thyroid goitre&#44; patients with voice changes and previous cervical surgery&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> as reflected in the algorithm in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; Therefore&#44; preoperative assessment of VCs with a screening technique such as CU&#44; coupled with the routine use of intraoperative neuromonitoring&#44; would decrease the risk of overlooking VC palsy&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Our work has several limitations&#46; Firstly&#44; it is a non-comparative study&#46; The lack of a control group using FL&#44; the reference technique in the evaluation of VCs&#44; is the main limitation&#46; Moreover&#44; the operators are not experts in CU&#44; despite having been trained with at least 100 cases of cervical ultrasound&#46; Even so&#44; the learning curve described in other articles&#44; as well as the peculiarities of the technique itself &#40;operator dependent&#41; contribute to a certain degree of heterogeneity in the results&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;19</span></a> Finally&#44; the selection of patients with no known previous VC palsy is another limitation&#44; even if this information was withheld from the evaluators&#46; Studies of &#8220;normal&#8221; anatomy usually exclude patients undergoing radiotherapy or with previous cervical surgery&#44; so the results cannot be fully extrapolated to the main population at hand&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In conclusion&#44; CU is an easy technique to implement in an endocrine surgery unit when performed by the surgeons themselves&#44; allowing the evaluation of VCs&#44; especially in young women&#46; The possibility of being an examination performed by endocrine surgeons at the bedside&#44; without relying on techniques performed by external services&#44; and the fact that it is a non-invasive procedure&#44; makes CU a good tool for VC screening in the preoperative evaluation of patients who are candidates for thyroid surgery and in the planning of the surgical intervention&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Authorship</span><p id="par0125" class="elsevierStylePara elsevierViewall">L&#46; E&#46; P&#233;rez-S&#225;nchez&#44; E&#46; Caballero-Rodr&#237;guez&#44; J&#46;C&#46; Jord&#225;n-Balanza&#58; planning&#44; study design and data collection&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">L&#46; E&#46; P&#233;rez-S&#225;nchez y R&#46; Orti-Rodr&#237;guez&#58; writing of the manuscript&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">A&#46; Soto-S&#225;nchez y M&#46;A&#46; Garc&#237;a-Bello&#58; analysis and interpretatio of results&#46; All authors&#58; critical review&#44; reading and final approval of the manuscript&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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              "titulo" => "Introducci&#243;n"
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    "fechaRecibido" => "2021-07-19"
    "fechaAceptado" => "2021-09-27"
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          "clase" => "keyword"
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            0 => "Thyroid"
            1 => "Ultrasound"
            2 => "Vocal cord"
            3 => "Surgery"
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          "palabras" => array:4 [
            0 => "Tiroides"
            1 => "Ecograf&#237;a"
            2 => "Cuerda vocal"
            3 => "Cirug&#237;a"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Cervical ultrasound &#40;CE&#41; has emerged as a promising tool in recent years for vocal cord &#40;VC&#41; assessment in patients undergoing thyroid surgery&#46; Our aim is to assess the reliability of CE once implemented in an endocrine surgery unit and performed by the surgeons themselves&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material and method</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">86 participants with no history of laryngeal pathology or cervical surgery underwent CE by three independent endocrine surgeons&#46; Laryngeal structures and specifically the VCs were analysed&#46; To consider the examination as diagnostic&#44; the VCs had to be visualised statically and during phonation&#46; The time taken to perform the technique and the interobserver variability were also analysed&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Of the 86 participants&#44; 51&#46;2&#37; were male with a mean age of 43 years&#46; The range of diagnostic examinations between surgeons was 60&#8211;68&#37;&#44; with substantial agreement between the 3 explorers &#40;Fleiss&#8217;s K-value&#8201;&#61;&#8201;&#46;714&#41;&#46; Male sex and advanced age were factors associated with non-assessability of the technique&#46; The mean procedure time was 72&#8201;s&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">CE is a fast&#44; non-invasive&#44; feasible bedside tool useful for the assessment of VCs prior to thyroid surgery&#44; mainly in young women&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Material and method"
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          2 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La ecograf&#237;a cervical &#40;EC&#41; ha surgido como una herramienta prometedora en los &#250;ltimos a&#241;os para la evaluaci&#243;n de las cuerdas vocales &#40;CV&#41; en pacientes sometidos a cirug&#237;a de tiroides&#46; Nuestro objetivo es valorar la fiabilidad de la EC una vez implementada en una unidad de cirug&#237;a endocrina y realizada por los propios cirujanos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Material y m&#233;todo</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 86 participantes sin antecedentes de patolog&#237;a lar&#237;ngea ni cirug&#237;a cervical a los que se les realiz&#243; una EC por parte de 3 cirujanos endocrinos independientes&#46; Se analizaron las estructuras lar&#237;ngeas y espec&#237;ficamente las CV&#46; Para considerar la exploraci&#243;n como diagn&#243;stica&#44; deb&#237;an visualizarse las CV de manera est&#225;tica y durante la fonaci&#243;n&#46; Tambi&#233;n se analiz&#243; el tiempo de realizaci&#243;n de la t&#233;cnica y la variabilidad interobservador&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">De los 86 participantes&#44; el 51&#44;2&#37; fueron varones y una edad media de 43 a&#241;os&#46; El rango de exploraciones diagn&#243;sticas entre los cirujanos fue de 60&#8211;68&#37;&#44; con una concordancia sustancial entre los 3 exploradores &#40;valor K de Fleiss&#8217;s&#8201;&#61;&#8201;0&#46;714&#41;&#46; El sexo masculino y la edad avanzada fueron factores asociados a la no evaluabilidad de la t&#233;cnica&#46; El tiempo medio del procedimiento fue de 72 segundos&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusi&#243;n</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">La EC es una herramienta r&#225;pida&#44; no invasiva&#44; viable a pie de cama y &#250;til para la evaluar las CV antes de la cirug&#237;a tiroidea&#44; principalmente en mujeres j&#243;venes&#46;</p></span>"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#8201;&#61;&#8201;86&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age &#40;years&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">43 &#40;28&#8722;58&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Male sex&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">44 &#40;51&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Height &#40;</span>m<span class="elsevierStyleItalic">&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;68 &#40;1&#46;62&#8722;1&#46;77&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Weight &#40;</span>kg<span class="elsevierStyleItalic">&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72 &#40;65&#8722;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">BMI &#40;</span>kg&#47;m<span class="elsevierStyleSup">2</span><span class="elsevierStyleItalic">&#41;&#44; median &#40;IQR&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">25&#46;28 &#40;23&#8722;28&#46;19&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal weight &#40;BMI 18&#46;5&#8722;24&#46;9&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">41 &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Overweight &#40;BMI 25&#8722;29&#46;9&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesity grade <span class="elsevierStyleSmallCaps">i</span> &#40;BMI 30&#8722;34&#46;9&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesity grade <span class="elsevierStyleSmallCaps">ii</span> &#40;BMI 35&#8722;39&#46;9&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">4 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesity grade <span class="elsevierStyleSmallCaps">iii</span> &#40;BMI 40&#8722;49&#46;9&#41;&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Operator A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Operator B&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Operator C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Technique time&#44; &#40;sc&#41;&#44; median &#40;IQR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;5 &#40;49&#46;2&#8722;86&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76 &#40;56&#46;2&#8722;94&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&#46;5 &#40;51&#46;2&#8722;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thyroid cartilage&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC muscle&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">VC free margin&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Arytenoid cartilage&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assessable VC&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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Original language: English
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