Laryngeal framework surgery for the management of aspiration

Dysphagia Outcomes Following Surgical Management of Unilateral Vocal Fold Immobility: A Systematic Review and Meta-analysis

OBJECTIVE

To assess dysphagia outcomes following surgical management of unilateral vocal fold immobility (UVFI) in adults.

DATA SOURCES

Ovid MEDLINE, Embase, Web of Science, and Cochrane Central.

REVIEW METHODS

A structured literature search was utilized, and a 2-researcher systematic review was performed following PRISMA guidelines. Extractable data were pooled, and a quantitative analysis was performed with a random effects model to analyze treatment outcome and complications by procedure.

RESULTS

A total of 416 publications were screened and 26 met inclusion criteria. Subjects encompassed 959 patients with UVFI who underwent 916 procedures (n = 547, injection laryngoplasty; n = 357, laryngeal framework surgery; n = 12, laryngeal reinnervation). An overall 615 were identified as having dysphagia as a result of UVFI and had individually extractable outcome data, which served as the basis for a quantitative meta-analysis. In general, dysphagia outcomes after all medialization procedures were strongly positive. Quantitative analysis demonstrated a success rate estimate of 90% (95% CI, 75%-100%) for injection laryngoplasty and 92% (95% CI, 87%-97%) for laryngeal framework surgery. The estimated complication rate was 7% (95% CI, 2%-13%) for injection laryngoplasty and 15% (95% CI, 10%-20%) for laryngeal framework surgery, with minor complications predominating. Although laryngeal reinnervation could not be assessed quantitatively due to low numbers, qualitative analysis demonstrated consistent benefit for a majority of patients for each procedure.

CONCLUSION

Dysphagia due to UVFI can be improved in a majority of patients with surgical procedures intended to improve glottal competence, with a low risk of complications. Injection laryngoplasty and laryngeal framework surgery appear to be efficacious and safe, and laryngeal reinnervation may be a promising new option for select patients.

Guidelines for the Management of Unilateral Vocal Fold Paralysis From the Korean Society of Laryngology, Phoniatrics and Logopedics

The Korean Society of Laryngology, Phoniatrics and Logopedics appointed a task force to establish clinical practice guidelines for the management of unilateral vocal fold paralysis (UVFP). These guidelines cover a comprehensive range of management-related factors, including the diagnosis and treatment of UVFP, and provide in-depth information based on current, up-to-date knowledge. Detailed evidence profiles are provided for each recommendation. The CORE databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers, using a predefined search strategy. When insufficient evidence existed, expert opinions and Delphi questionnaires were used to fill the evidence gap. The committee developed 16 evidence-based recommendations in six categories: initial evaluation (R1–4), spontaneous recovery (R5), medical treatment (R6), surgical treatment (R7–14), voice therapy (R15), and aspiration prevention (R16). The goal of these guidelines is to assist general otolaryngologists and speech-language pathologists who are primarily responsible for treating patients with UVFP. These guidelines are also intended to facilitate understanding of the condition among other health-care providers, including primary care physicians, nurses, and policy-makers.

Pre- and intraoperative acoustic and functional assessment of the novel APrevent® VOIS implant during routine medialization thyroplasty

PURPOSE

Persistent unilateral vocal fold paralysis (UFVP) with glottal insufficiency often requires type I medialization thyroplasty (MT). Previous implants cannot be adjusted postoperatively if necessary. The newly developed APrevent^® VOIS implant (VOIS) can provide postoperative re-adjustment to avoid revision MT. The objective of this pilot study is to evaluate the VOIS intraoperatively concerning voice improvement, surgical feasibility and device handling.

METHODS

During routine MT, VOIS was applied short time in eight patients before the regular implantation of the Titanium Vocal Fold Medialization Implant (TVFMI™). In all patients, perceptual voice sound analysis using R(oughness)-B(reathiness)-H(oarseness)-scale, measurement of M(aximum)-P(honation)-T(ime) and glottal closure in videolaryngoscopy were performed before and after implanting VOIS/TVFMI™. Acoustic analyses of voice recordings were performed using freeware praat. Surgical feasibility, operative handling and device fitting of VOIS and TVFMI™ were assessed by the surgeon using V(isual)-A(nalog)-S(cale). Data were statistically analyzed with paired t test.

RESULT

All patients showed significant improvement of voice sound parameters after VOIS/TVFMI™ implantation. The mean RBH-scale improved from preoperative R = 2.1, B = 2.3, H = 2.5 to R = 0.6, B = 0.3, H = 0.8 after VOIS and R = 0.5, B = 0.3, H = 0.8 after TVFMI™ implantation. The mean MPT increased from preoperative 7.9 to 14.6 s after VOIS and 13.8 s after TVFMI™ implantation. VOIS/TVFMI™ achieved complete glottal closure in 7/8 patients. The satisfaction with intraoperative device fitting and device handling of VOIS was as good as that of TVFMI™.

CONCLUSION

The novel APrevent^® VOIS implant showed similar intraoperative voice improvement compared to routinely used TVFMI™ without adverse device events and with safe device fitting.

Voice outcomes following medialization laryngoplasty with and without arytenoid adduction

OBJECTIVE

Voice outcomes following medialization laryngoplasty (ML) for unilateral vocal fold paralysis (UVFP) were compared to those who underwent ML plus arytenoid adduction (AA) (ML+AA).

METHODS

Single institution retrospective review of patients with UVFP undergoing ML and ML+AA (2009-2017). Demographic information and history of laryngeal procedures were collected. Preoperative and postoperative Voice Handicap Index-10 (VHI-10) and Consensus Perceptual Auditory Evaluation of Voice (CAPE-V) were assessed.

RESULTS

Of 236 patients, 119 met study criteria. Of those, 70 (59%) underwent ML and 49 (41%) underwent ML+AA. Significant differences between groups at baseline were found for age at time of thyroplasty (P = 0.046), VHI-10 scores (P < 0.001), and CAPE-V scores (P = 0.007). Baseline VHI-10 scores for ML+AA (28 ± 7) were greater than those for ML alone (24 ± 7). At 12 months, overall VHI-10 scores improved compared to baseline for both groups (ML+AA = 9 ± 7, ML = 16 ± 9); however, there was greater improvement for the ML+AA group compared to ML group (P = 0.001). CAPE-V scores at 3 or 12 months improved, but differences between the groups were not statistically significant once controlled for covariates.

CONCLUSION

Based on current findings, patients who undergo ML+AA likely have greater voice handicap at baseline compared to those undergoing ML alone. Patients selected for ML+AA improve as much or more than those who underwent ML alone. This highlights the importance of appropriate selection of candidates for AA.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1876-1881, 2019.

Iatrogenic skull base cholesteatoma

While the impact of injection laryngoplasty on voice outcomes in unilateral vocal fold immobility has been well characterized, there is a relative paucity of literature investigating its influence on swallow function and outcomes. We performed a retrospective chart review of patients presenting to an academic cancer center between January 2014 and January 2016 to evaluate the clinical impact of percutaneous injection laryngoplasty on reduction of aspiration risk, patient perception of swallowing, and recommended safe diet in patients with vocal fold immobility after head and neck and thoracic surgery. A consecutive sample of patients diagnosed with unilateral vocal fold immobility with patient- or clinician-identified abnormal swallow function who underwent bedside or in-office vocal fold injection was included in the study. Fiberoptic endoscopic evaluation of swallowing, Eating Assessment Tool-10 scores, Functional Oral Intake Scale scores, and patient perceptual assessment of swallow were evaluated pre- and postinjection. Twenty-one patients with new-onset unilateral vocal fold immobility who underwent injection laryngoplasty were evaluated. Median Eating Assessment Tool-10 and Functional Oral Intake Scale scores postinjection were significantly improved from preinjection. Patients who initially required restricted oral diets, or were nil per os, were able to advance their diet after injection laryngoplasty. Injection laryngoplasty is a safe and effective intervention for improvement of dysphagia in patients with unilateral vocal fold immobility. A single treatment may markedly reduce or eliminate risk of aspiration and potential sequelae.

Improved swallow outcomes after injection laryngoplasty in unilateral vocal fold immobility

While the impact of injection laryngoplasty on voice outcomes in unilateral vocal fold immobility has been well characterized, there is a relative paucity of literature investigating its influence on swallow function and outcomes. We performed a retrospective chart review of patients presenting to an academic cancer center between January 2014 and January 2016 to evaluate the clinical impact of percutaneous injection laryngoplasty on reduction of aspiration risk, patient perception of swallowing, and recommended safe diet in patients with vocal fold immobility after head and neck and thoracic surgery. A consecutive sample of patients diagnosed with unilateral vocal fold immobility with patient- or clinician-identified abnormal swallow function who underwent bedside or in-office vocal fold injection was included in the study. Fiberoptic endoscopic evaluation of swallowing, Eating Assessment Tool-10 scores, Functional Oral Intake Scale scores, and patient perceptual assessment of swallow were evaluated pre- and postinjection. Twenty-one patients with new-onset unilateral vocal fold immobility who underwent injection laryngoplasty were evaluated. Median Eating Assessment Tool-10 and Functional Oral Intake Scale scores postinjection were significantly improved from preinjection. Patients who initially required restricted oral diets, or were nil per os, were able to advance their diet after injection laryngoplasty. Injection laryngoplasty is a safe and effective intervention for improvement of dysphagia in patients with unilateral vocal fold immobility. A single treatment may markedly reduce or eliminate risk of aspiration and potential sequelae.

Multi-institutional Evaluation of Medialization Laryngoplasty in the Elderly

Objective

To evaluate voice outcomes of medialization laryngoplasty in the elderly population (65 years and older) and to identify swallow outcomes, complication rates, and predictors of voice outcomes.

Study Design

Case series with chart review.

Setting

Two tertiary academic medical centers.

Subjects and Methods

We retrospectively reviewed charts of 136 patients age 65 years and older undergoing medialization laryngoplasty between January 2008 and May 2016 at 2 tertiary academic institutions. Primary outcome was assessed using Voice Handicap Index 10 (VHI-10) score and Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) score. Secondary outcomes were assessed using the Eating Assessment Tool 10 (EAT-10) when dysphagia was present, stroboscopic analysis of glottic closure, and complication rates. A logistic regression analysis assessed predictors of voice improvement after medialization laryngoplasty.

Results

Total GRBAS and VHI-10 scores showed a significant improvement postoperatively ( P < .05). A ≥20% improvement was seen in 81.6% of patients, and a ≥50% improvement was seen in 53.7%. No patient had major complications. Minor complications occurred in 5.9% of patients. Multivariable logistic regression identified preoperative injection augmentation as an independent predictor of less improvement in VHI-10 score ( P = .015). Voice therapy prior to medialization did not affect voice outcomes ( P = .640).

Conclusion

Patient- and provider-perceived voice quality are significantly improved after medialization laryngoplasty in the elderly, and the procedure is associated with a low complication rate even in an elderly cohort. Improvement in patient-perceived voice outcomes after medialization laryngoplasty was diminished in patients with preoperative injection augmentation.

Vocal palsy increases the risk of lower respiratory tract infection in low-risk, low-morbidity patients undergoing thyroidectomy for benign disease: A big data analysis

OBJECTIVES

Thyroidectomy is the commonest operation that places normally functioning laryngeal nerves at risk of injury. Vocal palsy is a major risk factor for dysphonia, dysphagia, and less commonly, airway obstruction. We investigated the association between post-thyroidectomy vocal palsy and long-term risks of pneumonia and laryngeal failure.

DESIGN

An N=near-all analysis of the English administrative dataset using a previously validated informatics algorithm to identify young and otherwise low-risk patients undergoing first-time elective thyroidectomy for benign disease. Information about age, sex, morbidities, social deprivation and post-operative and late complications were derived.

MAIN OUTCOME MEASURES

Between 2004 and 2012, 43 515 patients between the ages of 20 and 69 who had no history of cancer, neurological, or respiratory disease underwent elective total or hemithyroidectomy without concomitant or late neck dissection, parathyroidectomy or laryngotracheal surgery for benign thyroid disease for the first and only time. Information about age, sex, morbidities and in-hospital and late complications was recorded.

RESULTS

Mean age at surgery was 46±12. There was a strong female preponderance (85%), and most patients (89%) had no recorded Charlson comorbidities Most patients (65%) underwent hemithyroidectomy. Late vocal palsy was recorded in 449 (1.03%) patients, and its occurrence was an independent risk factor for emergency hospital readmission (n=7113; Hazard Ratio 1.52; 95% confidence interval 1.21-1.91), hospitalisation for lower respiratory tract infection (n=944; HR 2.04; 95% CI 1.07-3.75), dysphagia (n=564; HR 3.47; 95% CI 1.57-7.65) and gastrostomy/tracheostomy placement (n=80; HR 20.8; 95% CI 2.5-171.2). Independent risk factors for late vocal palsy were age, burden of morbidities, total thyroidectomy, post operative bleeding, male sex, and annual surgeon volume <30.

CONCLUSIONS

There is a significant association between post-thyroidectomy vocal palsy and long-term risks of hospital readmission, dysphagia, hospitalisation for lower respiratory tract infection, and gastrostomy/tracheostomy tube placement. This adds weight to the need, from a thyroid surgical perspective, to undertake universal post-thyroidectomy laryngeal surveillance as a minimum standard of care, with a focus on post-operative dysphagia and aspiration, and from a medical/respiratory perspective, to initiate investigations to identify occult vocal palsy in patients who present with pneumonia, who have a history of thyroid surgery.

One hundred years of external approach medialisation thyroplasty

It has been 100 years since Erwin Payr first developed an operation to improve the effects of a paralysed vocal fold, and operations based on this technique are still in use today. This technique, medialisation thyroplasty, aims to improve the symptoms caused by vocal fold palsy by realigning the lateralised vocal fold into the midline.

Whilst the effects of vocal fold palsy were recognised in antiquity, it was only with the development of indirect laryngoscopy in the late nineteenth century that the vocal fold paralysis could be identified as an aetiology for poor phonation and dysphagia. Payr, in 1915, was the first to perform a recognisable form of medialisation thyroplasty, which was further developed in the early twentieth century, but medialisation thyroplasty did not begin to be widely used until the development of the modern technique by Isshiki et al., in 1974.

Since then, medialisation thyroplasty has continued to be developed and is currently the most widely used technique for correcting the effects of vocal fold palsy. However, a wide array of therapeutic options is now available for vocal fold palsy and it is impossible to say whether or not medialisation thyroplasty will still be used in another 100 years.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

European Society for Swallowing Disorders - European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome

This position document has been developed by the Dysphagia Working Group, a committee of members from the European Society for Swallowing Disorders and the European Union Geriatric Medicine Society, and invited experts. It consists of 12 sections that cover all aspects of clinical management of oropharyngeal dysphagia (OD) related to geriatric medicine and discusses prevalence, quality of life, and legal and ethical issues, as well as health economics and social burden. OD constitutes impaired or uncomfortable transit of food or liquids from the oral cavity to the esophagus, and it is included in the World Health Organization's classification of diseases. It can cause severe complications such as malnutrition, dehydration, respiratory infections, aspiration pneumonia, and increased readmissions, institutionalization, and morbimortality. OD is a prevalent and serious problem among all phenotypes of older patients as oropharyngeal swallow response is impaired in older people and can cause aspiration. Despite its prevalence and severity, OD is still underdiagnosed and untreated in many medical centers. There are several validated clinical and instrumental methods (videofluoroscopy and fiberoptic endoscopic evaluation of swallowing) to diagnose OD, and treatment is mainly based on compensatory measures, although new treatments to stimulate the oropharyngeal swallow response are under research. OD matches the definition of a geriatric syndrome as it is highly prevalent among older people, is caused by multiple factors, is associated with several comorbidities and poor prognosis, and needs a multidimensional approach to be treated. OD should be given more importance and attention and thus be included in all standard screening protocols, treated, and regularly monitored to prevent its main complications. More research is needed to develop and standardize new treatments and management protocols for older patients with OD, which is a challenging mission for our societies.

Medialization thyroplasty for cancer-related unilateral vocal fold paralysis

Objective

To justify the application of medialization thyroplasty in Chinese patients with symptomatic cancer-related unilateral vocal fold paralysis (UVFP).

Study Design and Setting

Retrospective chart review from February 2000 to March 2006.

Results

Eighty-seven Chinese patients undergoing medialization thyroplasty for UVFP were included; there were no significant differences between the cancer-related and benign groups in terms of the speech and swallowing rehabilitation outcome and the perioperative complication rate ( P > 0.05). The median survival time of cancer-related UVFP patients from the date of medialization to death was 129 days. Age more than 65 years was identified as the only factor for a shorter survival period after medialization ( P = 0.040).

Conclusion

Medialization thyroplasty restores satisfactory speech and swallowing and has a low perioperative complication rate in Chinese patients with cancer-related UVFP. Postmedialization survival period was also reasonable.

Significance

Medialization thyroplasty is a justifiable treatment option for cancer-related UVFP.

Framework Surgery for Treatment of Unilateral Vocal Fold Paralysis

Laryngeal framework surgery is the current gold standard treatment for unilateral vocal fold paralysis. It provides a permanent solution to glottic insufficiency caused by injury to the recurrent laryngeal nerve. Various modifications to the original Isshiki type I laryngoplasty procedure have been described to improve voice and swallowing outcomes. The success of this procedure is highly dependent on the experience of the surgeon as it epitomizes the intersection of art and science in the field. The following article reviews the evidence, controversies, and complications related to laryngoplasty for unilateral vocal fold paralysis. It also provides a detailed analysis of how and when arytenoid-positioning procedures should be considered, and summarizes the literature on postoperative outcomes.

Cervical osteophytes causing vocal fold paralysis: case report and literature review

Objectives:

To increase awareness of cervical osteophytes as an extremely rare cause of recurrent laryngeal nerve palsy; to outline the clinical approach to patients with unilateral vocal fold paralysis and to provide an update on the current management of osteoarthritis and osteophytes.

Case report:

An elderly man presented with right unilateral vocal fold immobility and a small phonatory gap. By a diagnosis of exclusion, a cervical osteophyte at the level of the sixth and seventh cervical vertebrae was shown to be the cause. The patient responded to speech therapy and no further intervention was required.

Method:

A literature review, using Medline, identified only one previously published case of vocal fold paralysis due to osteophytes secondary to osteoarthritis.

Conclusion:

The aetiology of unilateral paralysis of the hemilarynx must be fully investigated, as the innervating system has a protracted course, particularly on the left side. Degenerative cervical spine disease, although rare, should be considered as part of the differential diagnosis.

Multiparameter comparison of injection laryngoplasty, medialization laryngoplasty, and arytenoid adduction in an excised larynx model

OBJECTIVES/HYPOTHESIS

Evaluate the effect of injection laryngoplasty (IL), medialization laryngoplasty (ML), and ML combined with arytenoid adduction (ML-AA) on acoustic, aerodynamic, and mucosal wave measurements in an excised larynx setup.

STUDY DESIGN

Comparative case study using ex vivo canine larynges.

METHODS

Measurements were recorded for eight excised canine larynges with simulated unilateral vocal fold paralysis before and after vocal fold injection with Cymetra. A second set of eight larynges was used to evaluate medialization laryngoplasty using a Silastic implant without and with arytenoid adduction.

RESULTS

IL and ML led to comparable decreases in phonation threshold flow (PTF), phonation threshold pressure (PTP), and phonation threshold power (PTW). ML-AA led to significant decreases in PTF (P = .008), PTP (P = .008), and PTW (P = .008). IL and ML led to approximately equal decreases in percent jitter and percent shimmer. ML-AA caused the greatest increase in signal-to-noise ratio. ML-AA discernibly decreased frequency (P = 0.059); a clear trend was not observed for IL or ML. IL significantly reduced mucosal wave amplitude (P = 0.002), whereas both ML and ML-AA increased it. All procedures significantly decreased glottal gap, with the most dramatic effects observed after ML-AA (P = 0.004).

CONCLUSIONS

ML-AA led to the greatest improvements in phonatory parameters. IL was comparable to ML aerodynamically and acoustically, but caused detrimental changes to the mucosal wave. Incremental improvements in parameters recorded from the same larynx were observed after ML and ML-AA. To ensure optimal acoustic outcome, the arytenoid must be correctly rotated. This study provides objective support for the combined ML-AA procedure in tolerant patients.

Gore-Tex medialization laryngoplasty for treatment of dysphagia

Objective: Gore-Tex medialization laryngoplasty is a well described procedure for the management of glottal incompetence with associated phonatory disturbance. Limited literature exists describing the use of this procedure in the management of dysphagia. We describe our experience with Gore-Tex medialization laryngoplasty and the treatment of dysphagia.

Study Design: Case series with chart review.

Setting: Tertiary referral center.

Subjects and Methods: Between April 2000 and September 2008, 189 Gore-Tex medialization laryngoplasties were performed on 180 patients by the senior author. Complete records and analysis were available for and performed on 121 procedures for 113 patients. The main outcome measures were discontinuation of gastrostomy tube (g-tube) use or avoidance of g-tube, as well as clinical subjective improvement in swallowing function.

Results: Fifty-seven of 113 (50%) patients had complaints of dysphagia at presentation, with 47 of 57 (82%) having an objective swallowing evaluation. Thirty-two of 47 (68%) had documented penetration and/or aspiration. Twenty of 57 (35%) patients with dysphagia required g-tubes for alimentation. Eleven of 20 (55%) patients were able to discontinue g-tube use after Gore-Tex medialization laryngoplasty, and an additional five patients with aspiration were able to avoid need for g-tubes with Gore-Tex medialization laryngoplasty and swallowing therapy.

Conclusions: Gore-Tex medialization laryngoplasty is a well tolerated and well described treatment for the management of glottal incompetence. The procedure is an appropriate adjunct in dysphagia management for the appropriate patient population.

[Diagnosis and treatment of functional oropharyngeal dysphagia. Features of interest to the digestive surgeon]

Digestive surgeons should form part of the multidisciplinary team managing patients with oropharyngeal dysphagia. These patients can be diagnosed through clinical methods and complementary investigations such as videofluoroscopy and pharyngoesophageal manometry. These techniques also allow specific treatment to be selected. Up to one-third of patients with dysphagia suffer from malnutrition as a result of alterations in food bolus transport. Furthermore, up to two-thirds show alterations in swallowing safety (penetrations and aspirations, especially when swallowing liquids), as well as a high risk of respiratory infections and aspiration pneumonia. Increasing food bolus viscosity to 3500-4000 mPas (pudding viscosity) improves the effectiveness of swallowing and reduces the risk of aspirations. Botulinic toxin injection in the upper esophageal sphincter is indicated in patients with spasticity of neuromuscular origin. Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum and is also indicated in patients with alterations in the upper esophageal sphincter and preserved oropharyngeal motor response.

Safety and cost-effectiveness of intra-office flexible videolaryngoscopy with transoral vocal fold injection in dysphagic patients

SETTING

A tertiary care referral-based otolaryngology practice.

OBJECTIVES

To evaluate the safety of office-based transoral oral vocal fold injection in an ambulatory dysphagic population and to evaluate cost-effectiveness in comparison with traditional injection laryngoplasty done under general anesthesia in the operating room. Dysphagia is a nonspecific and common symptom of many head and neck and systemic disease processes. In patients with glottal incompetence, the presenting complaint of dysphagia generally portends to more global oropharyngeal dysfunction than dysphonia alone. Although many authors have reported on and advocated the use of office injection technique in the management of dysphonia caused by glottal insufficiency, there is a paucity of literature regarding the use of this technique in a more medically compromised dysphagic patient population (Ann Otol Rhinol Laryngol 1997;106:778-83). We describe our experience with vocal fold injection in the office setting using a transoral technique under flexible videolaryngoscopy for the treatment of glottal insufficiency in dysphagic patients. The safety and cost-effectiveness of this approach are highlighted.

The role of glottal gap in predicting aspiration in patients with unilateral vocal paralysis

Aspiration has been frequently noted among patients suffering from vocal-fold paralysis. The association between a defect of glottal closure and aspiration in patients with unilateral vocal paralysis appears to have been rarely reported. The current study reviews collected data consisting of videotaped flexible nasoendoscopy and stroboscopy for patients with a unilateral vocal-fold paralysis. Mean normalized glottal gap areas for patients suffering vocal paralysis with associated aspiration are significant greater than that for the non-aspiration group. Subsequent to the surgical correction of the glottal gap, all patients recovered well from their earlier aspiration. The investigation of objectively derived data revealed that poor airway protection due to incomplete closure of the vocal fold was the major cause of aspiration for patients suffering unilateral vocal-fold paralysis. Intracordal autologous fat injection can successfully improve the breath control and eliminate aspiration in patients with vocal-fold paralysis.

Patterns of swallowing failure following medialization in unilateral vocal fold immobility

OBJECTIVE

To quantify the incidence of penetration and aspiration following medialization for unilateral vocal cord immobility (UVCI) and determine patterns of failure.

STUDY DESIGN

Blinded analysis consecutive case series.

METHODS

Prospective blinded analysis of videofluoroscopic swallowing studies of patients who had received a medialization procedure was conducted, determining the incidence of penetration and aspiration by using the Penetration-Aspiration Scale. Pharyngeal transport measures were also assessed. Associations between clinical factors and penetration-aspiration were statistically determined.

RESULTS

Sixty-seven videofluoroscopic swallowing studies were reviewed in patients (mean age, 63.3 y) who had undergone vocal fold medialization (14 laryngoplasties and 53 vocal cord injections) for UVCI. Unilateral vocal cord immobility was left-sided in 56 patients (83.6%), and 50 patients (74.6%) had a postsurgical etiologic factor for their immobility. Thirty (44.8%) and 16 (23.9%) patients demonstrated penetration and aspiration, respectively. Penetration most often occurred during the swallow, but aspiration was equally likely to occur during or after the swallow. No differences in the incidence of penetration or aspiration were noted according to the side of vocal fold paralysis ( P=.20, chi test) or etiologic factor ( P=.69). Further analysis found that swallow factors significantly associated with penetration and aspiration were swallow delay ( P=.001, Wilcoxon ranked pairs test) and reduced laryngeal elevation ( P=.001), as well as bolus residues in the valleculae (P =.002), piriform sinus ( P=.001), or posterior pharynx (P =.008).

CONCLUSIONS

Many patients demonstrate significant radiographic aspiration even after medialization procedures for UVCI. Although glottal incompetence is a known risk factor for aspiration, other factors including pharyngeal bolus transport are important in determining an effective swallow in UVCI.

Complications of type I thyroplasty and arytenoid adduction

OBJECTIVES/HYPOTHESIS

Unilateral vocal fold paralysis resulting in glottal incompetence can cause significant morbidity attributable to impaired speech, swallowing, and ability to protect the airway. Type I thyroplasty in combination with arytenoid adduction is a proven technique for medialization of the paralyzed vocal fold but must be evaluated in light of potential complications following laryngeal framework surgery.

STUDY DESIGN AND METHODS

The charts of 237 patients who underwent unilateral vocal fold medialization surgery between July 1, 1991, and August 30, 1999, at a tertiary care cancer referral center were retrospectively reviewed.

RESULTS

There were 98 cases of type I thyroplasty alone and 96 cases of type I thyroplasty with arytenoid adduction. The two groups had similar patient characteristics. Mean time of surgery (45 vs. 73 min, P <.0001) and length of hospital stay (1.1 vs. 1.8 d, P <.0001) were increased when arytenoid adduction was performed. Overall improvement of symptoms was similar in both groups (93%-94%), but posterior glottic closure appeared subjectively improved when arytenoid adduction was used (P =.0054). Overall complication rates were slightly higher in the arytenoid adduction group (14% vs. 19%), primarily because of transient vocal fold edema and wound complications (9 vs. 19 cases), but the increase was not statistically significant (P =.1401). Complications warranting medical or surgical intervention occurred in 8% of cases. Two patients who underwent type I thyroplasty with arytenoid adduction required tracheotomy as a consequence of postoperative complications. The three patients who had extrusion of the implant underwent type I thyroplasty alone.

CONCLUSION

Using the appropriate technique, the potential benefits of improved glottic function following type I thyroplasty with arytenoid adduction outweigh the small risk of significant complications observed.

Immediate percutaneous medialization for acute vocal fold immobility with aspiration

OBJECTIVES

To determine the efficacy of immediate bedside or office percutaneous, trans-thyroidal injections of a bioabsorbable gelatin material (Gelfoam, Upjohn Co., Kalamazoo, MI) to decrease the risk of aspiration resulting from acute vocal fold immobility.

STUDY DESIGN

Retrospective review of patients presenting with acute vocal fold immobility and aspiration or high aspiration risk at an urban, tertiary care university hospital.

METHODS

All patients were evaluated by videostroboscopy, functional endoscopic evaluation of swallowing (FEES), and objective voice measures. Patients with acute vocal fold immobility and evidence of aspiration on history or FEES were given the option of medialization by Gelfoam injection. Injections were performed percutaneously in the office or at the bedside under laryngoscopic guidance. FEES was repeated after injection to verify improvement in aspiration.

RESULTS

Eleven patients underwent Gelfoam injection for treatment of aspiration and vocal fold immobility. All were significantly improved on post-injection FEES study. All patients were returned to an oral diet, avoiding the need for long-term enteral access.

CONCLUSION

Percutaneous Gelfoam injections is a rapid, temporary solution to the common problem of aspiration resulting from acute vocal fold immobility.