The Laryngoscope V C 2014 The American Laryngological, Rhinological and Otological Society, Inc. Laryngoscopic Characteristics in Vocal Leukoplakia: Inter-rater Reliability and Correlation With Histology Grading Chi-Kuang Young, MD; Wan-Ni Lin, MD; Li-Yu Lee, MD; Li-Ang Lee, MD; Li-Jen Hsin, MD; Chun-Ta Liao, MD; Huesh-Yu Li, MD, FACS, FICS; I-How Chen, MD; Tuan-Jen Fang, MD, FICS Objectives/Hypothesis: Vocal cord leukoplakia is a clinical diagnosis that comprises a spectrum of benignities, prema- lignancies, and malignancies. Accurate recordings of the visual characteristics of the affected area are important for communica- tion between physicians and are helpful in further management. The objective of this study was to determine the laryngoscopic characteristics among patients with vocal cord leukoplakia and the reliability of examinations between different raters. Study Design: Retrospective chart review conducted in a tertiary referral center in Taiwan. Methods: From January 2010 to April 2013, 107 consecutive patients with vocal leukoplakia who had accepted excisional biopsy were recruited and classified into two groups according to histologic findings. The patients without clear preoperative flexible laryngoscope images stored in the picture archiving and communication system were excluded. There were 68 patients who met the inclusion criteria, and the preoperative laryngoscope images were reviewed by two laryngologists. The inter-rater reliabilities of the recordings were assessed. Correlation between the variables and histologic classification was also performed. Results: The inter-rater reliability of the assessment was significant in the recordings of color, texture, size, hyperemia, thickness, and symmetry (j 5 0.267 to 0.573, P <.05) but not in vocal cord edema. The laryngoscopic findings including color, texture, size, and hyperemia were associated with the grade of dysplasia (P <.05). Conclusions: The specific proposed laryngoscopic characteristics are consistent in the recordings between raters and can be potentially used for stratifying patients’ risk. Key Words: Vocal leukoplakia, laryngoscopy, predictor. Level of Evidence: 4. Laryngoscope, 125:E62–E66, 2015 INTRODUCTION Vocal cord leukoplakia, Greek for white plaque, is a clinical descriptor indicating the keratin over the mucous membrane of the vocal folds. 1,2 Lesions can be either exo- phytic or flat depending on the thickness of the keratin layer of the epithelium. As noted in previous reports, 2,3 approximately 50% of patients with clinical vocal leuko- plakia had no dysplasia in histologic examination, but others had more aggressive findings. Moreover, from the histologic examination of the surrounding epithelium, the diagnosis of vocal cord leukoplakia may comprise a spec- trum from benign, premalignant, to malignant. 4 Patients with vocal cord leukoplakia usually display voice issues similar to other vocal fold lesions. Restoring voice capabilities as well as completely removing the lesion are the treatment goals for most cases. However, the management of such dysphonia from vocal cord leu- koplakia should also take histologic grades into consider- ation. For a case of vocal cord leukoplakia with high possibility of malignancy, eradicating the cancer cells in an early stage is more important, and deeper resection may be necessary. On the other hand, a conservative treatment or watch-and-wait policy benefits those with a low risk of malignancy. Thus, an accurate and delicate recording of the characteristics of vocal cord mucosa is helpful in further management. The mucosal appearance of the vocal leukoplakia can be classified into multiple factors such as the homo- geneity of color and regularity of texture. Recording the findings in a standard form is helpful for medical com- munication and follow-up. Thus, it is important to estab- lish a scoring system that is reliable and also has clinical significance. Although the surface appearance of the laryngeal mucosa was suggested to be unreliable in predicting the degree of dysplasia in the entire lesion, 5 with the devel- opment of the high-resolution flexible laryngoscope and quality digital imaging, it is possible to stratify the vocal cord leukoplakia by the morphologic characteristics in an office-based setting. The purpose of this study was to From the Department of Otolaryngology Head and Neck Surgery (C.-K.Y., W.-N.L, L-A.L., L.-J.H., C.-T.L., H.-Y .L., I.-H.C., T.-J.F .) and the Depart- ment of Pathology (L.-Y.L.), Chang Gung Memorial Hospital, Linkou, Taiwan; School of Medicine (W.-N.L, L-A.L., L.-J.H., C.-T.L., H.-Y .L., I.-H.C., T.-J.F .), Chang Gung University, Taoyuan, Taiwan; Chang Gung Memo- rial Hospital, Linkou, Taiwan. Editor’s Note: This Manuscript was accepted for publication July 23, 2014. The research was supported by a Chang Gung Medical Foundation Grant (CMRPG 3B1412). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors have no other funding, financial relationships, or con- flicts of interest to disclose. Tuan-Jen Fang contributed equally as first author. Send correspondence to Tuan-Jen Fang, MD, 5, Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan. E-mail: fang3109@cgmh.org.tw DOI: 10.1002/lary.24884 Laryngoscope 125: February 2015 Young et al.: Characteristics in Vocal Leukoplakia E62