Bilateral medialization laryngoplasty

Evidence of Long-Term Voice Therapy Effectiveness in Patients With Presbylarynges

Evidence for long-term effectiveness of voice therapy (>2 years from previous clinic visit) is lacking from patients over 60 years who initially presented with voice complaints and subsequently demonstrated videostroboscopic signs of aging leading to voice therapy recommendations. Over the telephone, a certified speech-language pathologist enquired from those compliant and non-compliant, whether their voices were better, stable, or worse since their previous clinic visit, and asked them to rate Voice-Related Quality of Life, voice satisfaction, and Glottal Function Index to compare with their previous clinic visit ratings. Further questions focused on current voice satisfaction, and for those who were compliant, therapeutic experiences including home exercises. Twenty-four participated (16 complied; eight non-compliant), with a mean of 3.7 ± 1.2 years since the previous clinic visit. For those compliant, 0% reported better voices, 69% stable, and 31% worse. Most compliant participants (56%) attended between two and five therapy sessions. The most frequently reported therapy techniques were repeating nasal sounds/words; straw phonation; fewer words/breath group; and increasing pitch range. Eighty-one percent of compliant participants were given home exercises. They stopped regular practice a few months post-therapy but continued using them as rescue techniques. For those non-compliant, 88% reported better voices, 0% stable, and 12% worse. Most non-compliant participants (43%) reported lack of time as their reason for non-compliance. Most compliant participants reported stable voices, supporting voice therapy's role in maintaining voice function over time in the context of progressive aging. However, non-compliant participants were not associated with poorer voice quality over time.

Long-Term Voice Change in Presbylarynges Patients With and Without Intervention

PURPOSE

To explore long-term patient experience of treated and untreated presbylarynges patients two or more years after their previous clinic visit by their responses to a probe about the changes in voice (better, stable, or worse) and standardized rating scales either by phone or from clinic records. Congruences of rating differences between visits and probe responses were assessed.

METHODS

Thirty-seven participated prospectively and seven retrospectively. Better, stable, or worse probe responses and treatment follow-through were obtained. Self-rating scales, completed verbally or obtained from charts, were compared to the previous visit so differences between visits could be converted to be congruent with probe responses.

RESULTS

After a mean of 4.6 years, 44% (63% untreated) reported stable, 36% (38% untreated) worse, and 20% (89% untreated) better. Significantly greater proportions of untreated reported better/stable probe responses while treated reported worse (χ2; P = 0.038). Significantly better means for all ratings were found at follow-up for those with better probe responses, but mean ratings were not significantly worse for those with worse probe response. No significant congruences of rating differences between visits and probe responses were found. In untreated reporting stable probe response, a significantly greater proportion of those with previous clinic ratings within normal limits (WNL) maintained ratings WNL at follow-up (z-statistic; P = 0.0007).

CONCLUSIONS

Ratings WNL at the initial evaluation, especially voice-related quality of life and effort, were found to still be WNL after several years. Little congruence was found between rating differences and probe responses, especially for worse, suggesting need for developing more sensitive rating scales.

Objective Laryngoscopic Measures From Older Patients With Voice Complaints and Signs of Aging

PURPOSE

The purpose of this study was to use objective measures of glottal gap, bowing, and supraglottic compression from selected images of laryngoscopic examinations from adults over 60 years of age with voice complaints and signs of aging to test current hypotheses on whether degree of severity impacts treatment recommendations and potential follow-through with treatment.

METHOD

Records from 108 individuals 60 years or older with voice complaints and signs of aging were reviewed. Three objective measures (normalized glottal gap area [NGGA], total bowing index, and normalized true vocal fold width) were derived. Each measure was subsequently divided into three categories by severity: absence, small degree, or large degree. Nonparametric statistics tested associations between severity and treatment recommendations as well as potential follow-through.

RESULTS

Noninvasive treatments (observation/voice therapy) were marginally associated with no glottal gap (p = .09). More invasive treatments (injection/bilateral thyroplasty) were associated with glottal gaps being present (p = .026), but bilateral thyroplasty recommendations were not significantly associated with the largest gaps. Treatment modalities were not characterized by specific severity categories for any of the objective measures. No significant differences were found for any of the three objective measures between those who followed through with recommended treatment and those who did not.

DISCUSSION

Results demonstrated some support for current hypotheses on how degrees of severity of objective measures relate to treatment recommendations. Of the three measures, NGGA appears to be more informative regarding treatment recommendations and follow-through, but due to low power, larger sample sizes are needed to confirm clinical relevance.

Sulcus vocalis in spasmodic dysphonia-A retrospective study

BACKGROUND

Spasmodic dysphonia (SD) is a neurological condition of the larynx characterised by task specific, involuntary spasms of the intrinsic laryngeal muscles causing frequent voice breaks during speech. The current treatment modality involves Botulinum Toxin injections into the affected group of muscles. This has yielded satisfactory results in Adductor SD (ADSD) and mixed SD but not in Abductor SD (ABSD). Sulcus vocalis is a morphological condition of the vocal folds with invagination of the superficial epithelium into the lamina propria or deeper layers. It is characterised by breathiness in voice and hypophonia. In our voice clinic, patients diagnosed with SD were occasionally found to have a sulcus on flexible stroboscopy. Studies have revealed an asymmetric stimulation of both the adductor and abductor group of muscles in ABSD and a predominant possibly symmetric stimulation of the adductor group of muscles in ADSD. Our objective was to study any significant association between vocal fold sulcus and two groups within SD; group one being ADSD and group two being both ABSD and Mixed SD. A literature review did not reveal any studies suggesting an association between SD and vocal fold sulcus to date.

METHODS

A retrospective review of the stroboscopic video recordings as well as file records of all patients diagnosed with SD between January 2016 and September 2019 was conducted at our voice clinic. The first author was the laryngologist who had diagnosed SD and its type on the basis of hearing the voice and making the patient perform various vocal tasks with and without flexible videostroboscopy. The SD patients were divided into two groups with the first group consisting of ADSD patients and the second group consisting of ABSD as well as Mixed SD patients. The presence or absence of vocal fold sulcus was noted in all the SD patients. Odds ratio was used to establish statistical significance of the presence of vocal fold sulcus in the two SD groups.

RESULTS

Among the 106 patients of SD, 62 patients were males and 44 were females. A total of 84 patients were diagnosed as ADSD, 10 as ABSD and 12 as Mixed SD patients. Vocal fold sulcus was noted in 5 out of 84 patients of ADSD, 4 out of 10 patients of ABSD, and in 3 out of 12 patients of mixed SD. Odds Ratio of 7.37 (C.I. = 2.063-26.35) was obtained for the second group of patients i.e. ABSD and Mixed SD.

CONCLUSION

Our study revealed a significant association between patients of SD having an abductor component (ABSD and mixed SD) and vocal fold sulcus. The two hypothesis proposed for this are the possibility of asymmetrical adductor and abductor muscle stimulation in SD being responsible for the development of a vocal fold sulcus or the primary presence of a vocal fold sulcus contributing to altered sensory feedback resulting in SD. Further study to evaluate this, as well as a study of the vocal response to medialisation procedures for patients of ABSD with sulcus is recommended.

Coagulation of posterior cricoarytenoid muscles for abduction spasmodic dysphonia

INTRODUCTION

Spasmodic dysphonia (SD), a form of focal dystonia, has been defined as a neurogenic, task-specific disorder characterized by abrupt spasms of intrinsic laryngeal muscles that result in phonatory breaks. There are three classic types of SD: adductor SD, abductor (ABSD) and mixed SD. Compared with the more common adductor form, treatment of ABSD with botulinum toxin injection is related to a shorter efficacy and improvement in only about 70% of patients [Blitzer et al. in Laryngoscope 108:1435-1441, 1998]. Moreover, due to the possible loss of efficacy over time or patient refusal for repeated injections, surgical solutions for permanent or at least long-term results must be considered.

METHOD

The surgical technique we propose is based on transoral bilateral posterior cricoarytenoid muscle (PCA) coagulation by radiofrequency (Celon, pro surg 250-T30, Olympus, Germany, 10 W, in 3 spots, each side) under a microscope or rigid scope control. The procedure is performed in two sessions distant of 2-3 weeks to avoid the risk of bilateral vocal fold temporary paralysis in adduction. A 52-year-old female patient with no audible voicing, resistant to botulinum toxin and after failure of relaxation thyroplasty type III according to lssihki [Saito et al. in Case Rep Otolaryngol 2018:4280381, 2018] showed an improvement of the Voice Handicap Index (VHI-10) from 35/40 to 19/40. The patient was rated G2R3B2A1S2 according to GRABS scale.

CONCLUSION

PCA coagulation for ABSD is a safe and reusable surgical option. It is less invasive than other techniques described before. To the best of our knowledge, this technique was never reported before in this type of SD.

Evaluating Safety of Awake, Bilateral Injection Laryngoplasty for Bilateral Vocal Fold Atrophy

OBJECTIVE

Office-based injection laryngoplasty (IL) has emerged as a useful procedure for otolaryngologists to correct glottic insufficiency while avoiding the costs and risks of general anesthesia. This is the first study focused on addressing the safety of bilateral IL for bilateral vocal fold (VF) atrophy.

METHODS

Patient records were reviewed from Emory University Hospital Midtown during the period of 2005 to 2017. Patients who underwent awake, bilateral transthyrohyoid, transoral, transcricothyroid, or transthyroid cartilage IL for bilateral VF atrophy were analyzed. All procedures, including repeat injections, were bilateral. Complication rate was used to evaluate safety. Patients with vocal cord paralysis, paresis, scar, and sulcus were excluded from the study.

RESULTS

Total 174 procedures met inclusion criteria. There were four complications, yielding a complication rate of 2.3%. Complications included aborted cases for difficult anatomy or poor patient tolerance, injection material not resorbing, and a VF hematoma. No patients had any airway emergencies or required admission to the hospital or evaluation in the emergency room.

CONCLUSIONS

This study illustrates a low complication rate for awake, bilateral IL in treating bilateral VF atrophy. This supports other studies that promote the safety of this procedure in the awake setting. Complications were associated with patient tolerance, unique anatomy, and in one case, anticoagulant medication. The low complication rate supports the conclusion that bilateral medialization IL is safe to perform in the office-based, awake setting.

Functional Electrical Stimulation for Presbyphonia: A Prospective Randomized Trial

Objectives

The aim of this prospective study was to examine the effects of transcutaneous functional electrical stimulation (FES) in a group of elderly women with presbyphonia.

Study Design

Prospective randomized study.

Methods

Fourteen participants were enrolled prospectively and attributed randomly to two different treatment groups, where one group (n = 7) received 8 weeks of training (5 days a week), whereas the other group (n = 7) received 4 weeks of ineffective stimulation, followed by 4 weeks of effective training. Stimulation protocols were established during baseline examination and confirmed with endoscopy to ensure a glottal reaction. Numerous acoustical, vocal, patient‐centered, and respiratory parameters were obtained at several time points.

Results

Neither 4 weeks nor 8 weeks of functional electrical transcutaneous stimulation led to changes of vocal, acoustical, or respiratory parameters, apart from patient‐centered items (Voice Handicap Index 12, Voice‐Related Quality of Life), which improved over time. However, there were no differences between the two arms for both items.

Conclusions

Transcutaneous FES over 4 weeks and 8 weeks did not lead to significantly improved objective voice and acoustical parameters, which could be caused by the fact that the muscles of interest cannot be targeted specifically enough. However, we found a significant improvement of subjective voice perception and voice‐related quality of life in both groups. We explain this finding with an observer‐expectancy effect secondary to the very time‐consuming and elaborate study procedures.

Level of Evidence

1b Laryngoscope, 130:E662–E666, 2020

Bilateral Posterior Cricoarytenoid Myoneurectomy for Abductor Spasmodic Dysphonia

OBJECTIVE

To discuss the utility and outcomes of bilateral myoneurectomy for treatment of abductor spasmodic dysphonia.

METHODS

Bilateral myoneurectomy is a known treatment option for patients with adductor spasmodic dysphonia. Its use for treatment of abductor spasmodic dysphonia, however, has not been documented previously. In this case report, treatment and long-term outcomes of abductor spasmodic dysphonia with bilateral myoneurectomy are discussed.

RESULTS

A 50-year-old male presented with abductor spasmodic dysphonia. His initial Voice Handicap Index-10 (VHI-10) score was 29, and he had breathy breaks during 60 series. He had no improvement in vocal quality after 6 botulinum toxin injections over 21 months. He underwent staged bilateral posterior cricoarytenoid partial myoneurectomy, with the left posterior cricoarytenoid myoneurectomy performed 33 months after presentation and right posterior cricoarytenoid myectomy 11 months later. Eight years postoperatively, his VHI-10 score was 12. During postoperative 60 series, the patient demonstrated few breathy breaks. Overall, the patient reports improved quality of life and satisfaction with his voice.

CONCLUSION

This is the first report of a long-term follow-up data for bilateral, endoscopic, partial posterior cricoarytenoid muscle myoneurectomy to treat refractory abductor spasmodic dysphonia. Long-term VHI-10 results suggest improvement of symptoms, despite mild difficulty with 60 series. While botulinum toxin therapy is the mainstay of management for abductor spasmodic dysphonia, surgical treatment is a potential alternative at least for refractory cases.

Bilateral Vocal Fold Medialization: A Treatment for Abductor Spasmodic Dysphonia

INTRODUCTION

Abductor spasmodic dysphonia, a difficult-to-treat laryngologic condition, is characterized by spasms causing the vocal folds to remain abducted despite efforts to adduct them during phonation. Traditional treatment for abductor spasmodic dysphonia-botulinum toxin injection into the posterior cricoarytenoid muscle-can be both technically challenging and uncomfortable. Due to the difficulty of needle placement, it is often unsuccessful. The purpose of this investigation is to present a previously undescribed treatment for abductor spasmodic dysphonia-bilateral vocal fold medialization.

METHODS

A retrospective case review of all cases of abductor spasmodic dysphonia treated in a tertiary care laryngology practice with bilateral vocal fold medialization over a 10-year period was performed. The Voice Handicap Index and the Voice-Related Quality of Life surveys were utilized to assess patient satisfaction with voice outcome.

RESULTS

Six patients with abductor spasmodic dysphonia treated with bilateral vocal fold medialization were identified. Disease severity ranged from mild to severe. All six patients reported statistically significant improvement in nearly all Voice Handicap Index and Voice-Related Quality of Life parameters. They reported fewer voice breaks and greater ease of communication. Results were noted immediately and symptoms continue to be well controlled for many years following medialization.

CONCLUSIONS

Bilateral vocal fold medialization is a safe and effective treatment for abductor spasmodic dysphonia. It is performed under local anesthesia and provides phonation improvement in the short and long term.

Excised larynx evaluation of subthyroid cartilage approach to medialization thyroplasty

OBJECTIVES/HYPOTHESIS

To describe an alternative approach to medialization thyroplasty involving dissection underneath the thyroid cartilage with placement of a Gore-Tex implant, and to evaluate its effect on a range of phonatory measures using an excised canine larynx model.

STUDY DESIGN

Animal model.

METHODS

On each of eight excised canine larynges, the conditions of normal, paralysis, medialization thyroplasty by standard transthyroid cartilage approach, and medialization thyroplasty by experimental subthyroid cartilage approach were performed. Aerodynamic, acoustic, and mucosal wave parameters were measured for each condition.

RESULTS

Compared to the vocal fold paralysis state, both the transthyroid and subthyroid approaches for Gore-Tex insertion resulted in significant decreases in phonation threshold pressure and phonation threshold flow. Both approaches also significantly decreased percent jitter, decreased percent shimmer, and improved signal-to-noise ratio. The mucosal wave was preserved after insertion of the Gore-Tex implant for both approaches. For all the phonatory measures except phonation threshold flow, there were no significant differences between the transthyroid and subthyroid approaches.

CONCLUSIONS

Gore-Tex implantation via a subthyroid approach in an excised canine larynx model can produce effective medialization, preserve the mucosal wave, and significantly improve aerodynamic and acoustic parameters without meaningful difference compared to a traditional transthyroid approach. The subthyroid approach does not require creation of a thyroid cartilage window and could be a potentially valuable alternative method of performing medialization thyroplasty.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:675-681, 2018.

Treatment effectiveness for aging changes in the larynx

OBJECTIVES

To compare the effectiveness of injection augmentation and bilateral thyroplasty surgery in managing age-related changes of the larynx.

STUDY DESIGN

Retrospective chart review of patients treated with bilateral thyroplasty and/or injection augmentation.

METHODS

We evaluated 22 patients before and after treatment using: 1) normalized glottal gap area and normalized true vocal fold width from endoscopic images; 2) patient self-rating questionnaires; and 3) acoustic and aerodynamic measures.

RESULTS

Thyroplasty surgery resulted in 38% of patients demonstrating less bowing compared to 33% after injection, and 63% demonstrated less supraglottic activity compared to 43% after injection (P = 0.09). Change in mean Voice-Related Quality of Life (V-RQOL) scores was 25.5 after thyroplasty compared to -16.4 after injection (P < 0.05). Those exhibiting a greater than 20 change in V-RQOL after treatment were significantly more likely to report swallowing symptoms pretreatment.

CONCLUSION

Patients postinjection did not rate themselves on any questionnaires as significantly better compared to pretreatment, whereas patients post-thyroplasty rated themselves as significantly improved on all questionnaires. Patients post-thyroplasty rated their voices as significantly closer to their best voice than patients postinjection. Likewise, 64% of patients who had thyroplasty surgery reported a significant treatment effect compared to 33% for injection augmentation.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2572-2577, 2017.

Effect of voice therapy in sulcus vocalis: A single case study

BACKGROUND

Sulcus vocalis is a structural deformity of the vocal ligament. It is the focal invagination of the epithelium deeply attaching to the vocal ligament. There is a dearth of literature on the outcome of voice therapy in sulcus vocalis condition.

OBJECTIVE

The primary objective of this study was to document voice characteristics of sulcus vocalis and the secondary objective was to establish the efficacy of voice therapy in a patient with sulcus vocalis.

METHOD

A trial of voice therapy was given to the client who was diagnosed as having sulcus vocalis. Boon's facilitation techniques were used in voice therapy along with other techniques such as breath holding and push and pull approach prior to surgery. Acoustic, aerodynamic, perceptual, quantitative measures of voice quality and self-rating measurements were performed before and after voice therapy.

RESULTS

Improvement was noticed in 10/10 acoustic, 4/4 aerodynamic, perceptual, dysphonia severity index and voice handicap index scores, which hinted that voice therapy can be an option critically for clients with sulcus vocalis in the initial stage.

CONCLUSION

Voice therapy showed promising improvement in the study and it must be recommended as the initial treatment option before any surgical management.

Challenges and opportunities in the management of the aging voice

Presbyphonia, or age-related dysphonia, is a diagnosis of exclusion, and other comorbidities must be considered in a complete evaluation of elderly patients with dysphonia. The aging voice can have a significant effect on the quality of life of the patient. In addition to the molecular effects of aging on the laryngeal tissues, the etiology of presbyphonia is often multifactorial because of comorbidities in the other organ systems involved in phonation. After a comprehensive evaluation, presbyphonia may be treated conservatively with voice therapy or with a range of interventions. Research into tissue engineering and electrical reanimation offers future options for treatment of presbyphonia. Currently, a multidisciplinary approach offers the most complete improvement in the vocal quality of life in this patient population.

Palliative treatment of dysphonia and dysarthria

The focus of this article is the palliative treatment of a variety of dysphonic conditions. Symptomatic relief of hoarseness can be achieved by voice therapy, augmentative alternative communication modalities, and surgery. The causes of dysphonia addressed herein include amyotrophic lateral sclerosis, Parkinson's disease, multiple sclerosis, stroke, head and neck cancers requiring glossectomy or laryngectomy, unilateral vocal fold paralysis, and presbyphonia. Palliative treatment of dysphonia and voice disorders provides symptomatic relief but not a cure of the underlying disease state. For these patients there are a number of palliative interventions that can greatly improve their quality of life.

Aging thyroarytenoid and limb skeletal muscle: lessons in contrast

Voice production is vital throughout life because it allows for the communication of basic needs as well as the pursuit and enjoyment of social encounters. Unfortunately, for many older individuals the ability to produce voice is altered. Structural and functional declines in the neuromuscular system occur with aging and likely contribute to the modification of voice. One specific target of the aging process is the thyroarytenoid (TA) muscle, the primary muscle of voice production. The objectives of this overview article are to (1) share current findings related to the aging of limb skeletal muscle, (2) identify age-related morphological and physiological features of TA muscle, (3) compare and contrast age-related changes in TA with those in limb skeletal muscle, and (4) describe therapies for reversing sarcopenia in limb muscle and consider the applicability of these therapies for addressing vocal fold atrophy and age-related voice changes. The article shares current knowledge from the basic sciences related to skeletal muscle aging and compares/contrasts typical muscle aging to TA aging. Current evidence suggests that (1) the TA muscle undergoes notable remodeling with age, (2) aging of the TA is multifactorial, resulting from a myriad of neurologic, metabolic, and hormonal changes, many of which are distinct from the age-related processes of typical limb skeletal muscle, (3) investigation of the aging of the TA and its role in the aging of voice is in its infancy, and (4) potential behavioral and nonbehavioral therapies for reversing aging of the TA must be further examined.

Cricoid Chondrosarcoma Presenting as Arytenoid Hypertelorism

BACKGROUND

Arytenoid hypertelorism (arytenoid cartilages spaced too widely apart) appears to be the most common initial recognizable physical finding of cricoid chondrosarcoma. Nine cases from the Center for Voice Disorders are presented. With arytenoid hypertelorism caused by cricoid chondrosarcoma, usually the posterior larynx is open. In fact, patients with arytenoid hypertelorism caused by cricoid chondrosarcoma may be aphonic even though the anterior membranous vocal folds make contact during attempted phonation.

METHODS

Between 1991 and 2002, nine patients were diagnosed with cricoid chondrosarcoma. Patients' charts and video examinations were retrospectively evaluated for symptoms and the presence of arytenoid hypertelorism on endoscopic evaluation. Two were women, and seven were men, with a mean age of 70 (range 53-72) years at diagnosis.

RESULTS

Eight (88%) patients had aphonia or dysphonia caused by arytenoid hypertelorism as their presenting symptom. Six were diagnosed after failed medialization laryngoplasty or other laryngeal rehabilitation surgery. All nine patients had a low-grade tumor. The initial treatment in eight patients was hemicricoidectomy, and one patient had a total laryngectomy. In four cases, a second procedure was needed 1 to 6 years later because of recurrence. Seven patients are alive without clinically significant disease; one is alive with moderate disease, and one has died from an unrelated cause.

CONCLUSIONS

Severely dysphonic, elderly patients presenting with arytenoid hypertelorism of unknown cause should be evaluated by fiberoptic laryngoscopy and by computed tomography scan to rule out cricoid chondrosarcoma. Because these tumors behave so benignly, the authors recommend conservative surgery (unilateral hemicricoidectomy) as the diagnostic/treatment modality of choice.

Perspectives on medialization laryngoplasty

Medialization laryngoplasty has become the new gold standard for the permanent management of patients with vocal fold paralysis and paresis. This article reviews the conceptual developments of the diagnosis and management of patients with vocal fold paresis and paralysis. We identify the specifics of operative decision-making as well as surgical complications associated with medializationlaryngoplasty. The role of revision surgery is detailed. We suggest a standardized evaluation using both objective and subjective data for analysis of surgical outcomes.

Advances in the management of glottic insufficiency

PURPOSE OF REVIEW

Glottic insufficiency secondary to vocal fold scarring, atrophy, or paresis remains a clinically challenging problem for the laryngologist. Numerous methods have been described in the treatment of glottic insufficiency, belying the complexity of the problem. Type I thyroplasty and injection of fat, fascia, and gelatin powder have been the mainstay of treatment to date, but the ability to restore a normal mucosal waveform to a damaged vocal fold remains an elusive goal.

RECENT FINDINGS

Advances in the material and biomedical sciences have allowed the introduction of newer substances and techniques not only to medialize the vocal fold but also to help restore its viscoelastic properties as well. These substances include expanded polytetrafluoroethylene (ePTFE), collagen, cross-linked hyaluronic acid, micronized acellular human dermis calcium hydroxyapatite, and polydimethylsiloxane. ePTFE can be introduced through a window in the thyroid ala or placed intracordally, and the others can be injected either transorally or transcutaneously, allowing in-office placement under simple topical anesthesia.

SUMMARY

Although the ideal augmentation material and technique have yet to be devised, the laryngologist now has several options with which to address the problem of glottic insuffiency. Since the problem is complex and since it is possible that a customized solution may need to be devised on an individual basis, future laryngologists will need to be comfortable with the indications and applications that each material and technique will afford.

Fat augmentation for nonparalytic glottic insufficiency

While autogenous fat augmentation for glottic insufficiency has been used before, relatively little information is currently available on the effectiveness of fat injection in patients with nonparalytic glottic insufficiency resulting from problems such as various defects of vocal atrophy or sulcus vocalis. This paper compares retrospectively the efficiency of fat injection after surgery in patients with vocal atrophy (n = 16) and sulcus vocalis (n = 8). The perceptual acoustic and phonatory functions and videolaryngostroboscopic data were evaluated before and after fat augmentation in 24 patients. The mean follow-up time was 19.5 months. Fifteen patients displayed excellent results; 1 showed some improvement; 6 experienced postprocedure failure, and 2 were not available for follow-up analysis. Perceptual rating showed significant improvement in grade, roughness and breathiness (p < 0.05). The videolaryngostroboscopic rating showed significant improvements in vocal fold edge linearity, vocal fold vibration amplitude and mucosal wave excursion (p < 0.05). More improvement in vocal atrophy was observed compared with sulcus vocalis following fat injection procedures. Our research showed that middle defects improved more compared to those in the anterior and posterior area. Fat injection is an effective autogenous implant and may be considered as an option in the treatment of patients with vocal atrophy or sulcus vocalis. Although fat reabsorption was a problem, repeating the procedure could be considered.

Functional results after external vocal fold medialization thyroplasty with the titanium vocal fold medialization implant

OBJECTIVES/HYPOTHESIS

A persistent insufficiency of glottal closure is mostly a consequence of a unilateral vocal fold movement impairment. It can also be caused by vocal fold atrophy or scarring processes with regular bilateral respiratory vocal fold function. Because of consequential voice, breathing, and swallowing impairments, a functional surgical treatment is required. The goal of the study was to outline the functional results after medialization thyroplasty with the titanium vocal fold medialization implant according to Friedrich.

METHODS

In the period of 1999 to 2001, an external vocal fold medialization using the titanium implant was performed on 28 patients (12 women and 16 men). The patients were in the age range of 19 to 84 years. Twenty-two patients had a paralysis of the left-side vocal fold, and six patients, of the right-side vocal fold. Detailed functional examinations were executed on all patients before and after the surgery: perceptive voice sound analysis according to the "roughness, breathiness, and hoarseness" method, judgment of the s/z ratio and voice dysfunction index, voice range profile measurements, videostroboscopy, and pulmonary function tests. In case of dysphagia/aspiration, videofluoroscopy of swallowing was also performed. The respective data were statistically analyzed (paired t test, Wilcoxon-test).

RESULTS

All patients reported on improvement of voice, swallowing, and breathing functions postoperatively. Videostroboscopy revealed an almost complete glottal closure after surgery in all of the patients. All voice-related parameters showed a significant improvement. An increase of the laryngeal resistance by the medialization procedure could be excluded by analysis of the pulmonary function test.

CONCLUSIONS

The results confirm the external medialization of the vocal folds as an adequate method in the therapy of voice, swallowing, and breathing impairment attributable to an insufficient glottal closure. The titanium implant offers, apart from good tissue tolerability, the advantage of an easy, time-saving, and individually adjustable application during the operation.

Posterior cricoarytenoid myoplasty with medialization thyroplasty in the management of refractory abductor spasmodic dysphonia

Of the approximately 100,000 Americans with primary (idiopathic) laryngeal dystonia, 10% to 15% are thought to havethe abductor form. Botulinum A toxin injected into the posterior cricoarytenoid muscle and/or cricothyroid muscle has been employed as the "gold standard" for therapeutic management; however, successful results are significantly less frequent than with injections for the adductor form. This report describes a new phonosurgical procedure, posterior cricoarytenoid myoplasty with medialization thyroplasty, designed for these refractory patients. Posterior cricoarytenoid myoplasty with medialization thyroplasty has been performed on 3 patients with abductor laryngeal dystonia. All patients had failed at least 5 previous botulinum A injections to the posterior cricoarytenoid and cricothyroid muscles. All patients underwent preoperative and 3 postoperative (2 weeks, 3 months, and 1 year) phonatory analyses. Analysis consisted of recording an aloud reading of a standard passage while a blinded trained speech pathologist counted prolonged voiceless consonants. The patients also completed a satisfaction survey at 1 year. The results demonstrated significant, long-lasting, uniform reduction in breathy breaks in all subjects. The participants all judged their symptoms as greatly improved. Bilateral procedures may be necessary, but should be staged to prevent possible airway compromise. When applied appropriately, posterior cricoarytenoid myoplasty with medialization thyroplasty is a viable tool in the management of refractory abductor laryngeal dystonia.

Medialization laryngoplasty with Gore-Tex for voice restoration secondary to glottal incompetence: indications and observations

Gore-Tex has been used as an effective implant for medialization laryngoplasty in the management of paralytic dysphonia; however, reporting of large patient cohorts has been limited. Furthermore, the use of Gore-Tex in the treatment of glottal incompetence secondary to soft tissue defects has not yet been described. Finally, a number of the procedural nuances of using Gore-Tex have not been elucidated. A prospective investigation was done on 142 patients who underwent 152 Gore-Tex medialization laryngoplasties in 183 vocal folds from December 1997 to March 2002. The primary diagnoses prompting the 152 procedures were paralysis in 94, paresis in 18, cancer reconstruction in 14, sulcus vocalis in 6, atrophy in 3, trauma defect in 5, arytenoid dislocation in 3, bilateral paralysis in 3, bilateral paresis in 1, parkinsonism in 4, and neurologic aerodynamic dissociation in 1. One patient who underwent reconstruction of a complex cancer defect required endoscopic removal of the Gore-Tex because of persistent granulation. Clinical observations reveal that Gore-Tex is a versatile implant that is ideally suited for phonosurgical reconstruction of aerodynamic glottal incompetence secondary to a variety of causes. Gore-Tex was especially useful for medialization of complex anatomic soft tissue defects such as those resulting from cancer resection, trauma, atrophy, and sulcus vocalis. There was superior ease in handling, placement, and in vivo adjustability.

Management of common voice problems: Committee report

OBJECTIVE

This report provides the reader with a state-of-the-art update on a number of common voice problems that require phonosurgical intervention.

STUDY DESIGN AND SETTING

This multiauthor review is not a position statement of the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) and may reflect institutional preference and/or bias. It arose from a panel discussion at the AAOHNS meeting in 2000.

RESULTS

We provide a review of the genesis and management of papillomatosis, dysplastic glottal epithelium, arytenoid granulomas, Reinke's edema, and vocal-fold paralysis.

CONCLUSIONS AND SIGNIFICANCE

In the past decade, there has been a dramatic expansion of knowledge regarding a variety of voice disorders and associated treatment. There has been a convergence of basic science investigations in anatomy, physiology, and pathology with clinical trials of treatment, both surgical and nonsurgical. This information should provide the reader with current insight into critical management issues of the aforementioned disorders.

Quantitative analysis of videostroboscopic images in presbylarynges

OBJECTIVE/HYPOTHESIS

Age-related dysphonia, or presbylarynges, is often identified as the cause of voice disorders in older individuals. It is a diagnosis of exclusion that typically includes the subjective videostroboscopic findings of vocal fold bowing or atrophy and incomplete glottal closure. We hypothesize that vocal fold bowing correlates directly with glottal gap in patients with presbylarynges and that these characteristics may be quantified objectively using measures obtained from videostroboscopic images.

STUDY DESIGN

Retrospective analysis of patient data and prospective analysis of control subjects.

METHODS

The quantitative measures of bowing index and normalized glottal gap, as well as a novel measure, normalized laryngeal outlet, were calculated from the videostroboscopic examinations of 46 patients with presbylarynges and 20 normal control subjects.

RESULTS

The mean bowing index values from the presbylarynges and control groups differed significantly, although there was overlap of individual values between groups. Bowing index values did not consistently predict normalized glottal gap values. Mean normalized laryngeal outlet values of the patients with presbylarynges were significantly smaller than those of the control group.

CONCLUSIONS

Bowing does not consistently predict the extent of glottal gap. Therefore, other presbylaryngeal changes are probably contributing to incomplete glottal closure, which are not well-visualized stroboscopically, so the finding of bowing is not sufficiently specific to identify presbylarynges. The significantly smaller normalized laryngeal outlet values suggest that this identifies a compensatory strategy for glottal gap to optimize vocal function. This is a novel finding that contrasts with medial ventricular fold squeezing, which is more routinely sought and is typically considered a maladaptive compensatory strategy. Despite the advantages of quantitative stroboscopic measures, limitations in reliability limit their clinical utility.

Vagal neuropathy after upper respiratory infection: a viral etiology?

PURPOSE

To describe a condition that occurs following an upper respiratory illness, which represents injury to various branches of the vagus nerve. Patients with this condition may present with breathy dysphonia, vocal fatigue, effortful phonation, odynophonia, cough, globus, and/or dysphagia, lasting long after resolution of the acute viral illness. The patterns of symptoms and findings in this condition are consistent with the hypothesis that viral infection causes or triggers vagal dysfunction. This so-called postviral vagal neuropathy (PVVN) appears to have similarities with other postviral neuropathic disorders, such as glossopharyngeal neuralgia and Bell's palsy.

MATERIALS AND METHODS

Five patients were identified with PVVN. Each patient's chart was reviewed, and elements of the history were recorded.

RESULTS

Each of the 5 patients showed different features of PVVN.

CONCLUSIONS

Respiratory infection can trigger or cause vocal fold paresis, laryngopharyngeal reflux, and neuropathic pain.

Assessment of posterior cricoarytenoid botulinum toxin injections in patients with abductor spasmodic dysphonia

In this study, we compared 2 techniques for injection of botulinum toxin type A (Botox) into the posterior cricoarytenoid (PCA) muscle for the treatment of abductor spasmodic dysphonia (ABSD). Fifteen patients with ABSD were enrolled in a prospective randomized crossover treatment trial comparing the 2 injection techniques. The PCA muscle was injected with 5 units on each side, with the injections staged 2 weeks apart, via either a percutaneous posterior-lateral approach or a transnasal fiberoptic approach. Eleven patients reported some benefit with the injections; however, the patient-perceived benefits were not related to changes in symptoms on blinded counts by speech pathologists. No significant reductions in the numbers of breathy breaks occurred with either technique, and no differences were found between techniques. Although patients perceived a benefit, blinded symptom counts did not substantiate these benefits. Thus, PCA muscle injections of Botox provided limited benefits to patients with ABSD, demonstrating the need for a more effective therapy for these patients.

Fascia Augmentation of the Vocal Fold: Graft Yield in the Canine and Preliminary Clinical Experience

INTRODUCTION

Glottal insufficiency resulting from vocal fold bowing, hypomobility, or scar is frequently treated by injection augmentation. Injection augmentation with fat, collagen, gel foam, polytef, and recently, fascia lata has been previously reported. Variable graft yield and poor host-tissue tolerance have motivated the continued search for an ideal graft substance.

STUDY DESIGN

A prospective trial of autologous fascia augmentation of the vocal cord in the human and in an animal model.

METHODS

Autologous fascia injection augmentation (AFIA) was evaluated in 8 canines and 40 patients at our institution between 1998 and 2000. The animal study compared graft yield from AFIA with autologous fat yield. The outcome measure was graft yield calculated from histological examination of larynges 12 weeks after injection augmentation. Clinical trial outcome measures included symptom surveys, acoustical voice analyses, and subjective voice assessments. Mean follow-up was 9 months.

RESULTS

In the canine larynx, the mean graft yield for AFIA was 33% (range, 5%-84%) compared with autologous lipoinjection (47%; range, 7%-96%; P =.57). Subjective improvement in vocal quality was reported by 95% of patients (38 of 40) after AFIA. Preoperative and postoperative voice analysis data were obtained from 26 patients. Subjective voice rating demonstrated a significant improvement after AFIA (P <.0001). Acoustical parameters of jitter, shimmer, noise-to-harmonic ratio, phonatory range, and degree unvoiced improved significantly (P <.05) in all patients after fascia augmentation.

CONCLUSIONS

Based on the animal study, we concluded that graft yields are excellent but variable for AFIA. The result is similar in variability and overall yield to autologous lipoinjection. Subjective and objective analyses of voice outcomes after AFIA are universally improved. Fascia appears to be an excellent alternative to lipoinjection in properly selected cases of glottic insufficiency.

Concomitant type I thyroplasty and thoracic operations for lung cancer: preventing respiratory complications associated with vagus or recurrent laryngeal nerve injury

OBJECTIVES

We sought to prevent postoperative swallowing disorder, aspiration, and sputum retention in cases of recurrent laryngeal or vagus nerve section occurring during lung cancer resection.

METHODS

In 14 of 25 consecutive patients, type I thyroplasty and thoracic operations were performed during the same period of anesthesia. All patients had a preoperative laryngeal computed tomographic scan providing us with indispensable measurements for vocal fold medialization under general anesthesia (ie, without intraoperative phonatory control). Nine remaining patients had a type I thyroplasty delayed from thoracic operations because of intraoperative doubt about laryngeal innervation injury, and 2 did not need a laryngeal operation. Main postoperative records consisted of swallowing ability, respiratory complications, and quality of voice.

RESULTS

No swallowing disorder, aspiration, or sputum retention occurred in cases of concomitant laryngeal and thoracic operations. Of these 14 patients, a single case (7%) of major complication (vocal fold overmedialization) occurred and required an early and successful revision thyroplasty; one case of cervical hematoma that did not require surgical drainage was considered a minor complication (7%). Twelve (86%) patients who underwent the concomitant association of both operations were fully satisfied with their quality of voice.

CONCLUSIONS

Type I thyroplasty and thoracic operation can be advantageously associated in case of injury to laryngeal motor innervation to prevent postoperative swallowing disability and dramatic respiratory complications.

Occult laryngeal pathology in a community-based cohort

BACKGROUND

Little information is available regarding the prevalence of laryngeal pathology in adults.

PURPOSE

To estimate the prevalence of occult laryngeal pathology in a community-based cohort of adults over 40 years of age.

METHODS

One hundred consecutive volunteers over age 40 with no history of voice disorders were enrolled. All completed a self-administered laryngeal symptom questionnaire and underwent a comprehensive head and neck examination including transnasal fiberoptic laryngoscopy.

RESULTS

The mean age of the cohort was 61 years. Vocal fold bowing (presbylaryngis) was present in 72% of the patients, and findings of laryngopharyngeal reflux were present in 64% of the cohort. In addition, other laryngeal pathology were identified in 21%. Only 12% had a completely normal laryngeal examination.

CONCLUSIONS

Occult laryngeal pathology is very common in persons over 40. Findings suggestive of laryngopharyngeal reflux are present in 64%, and vocal fold bowing is present in 72% of persons over 40.

Arytenoid adduction and medialization laryngoplasty

Arytenoid adduction and medialization laryngoplasty have become the mainstay of static surgical rehabilitation of the larynx after vocal fold paralysis. The rationale for considering one versus a combination of the two procedures has not been well addressed. This article outlines the basic science of the procedures and the clinical technical modifications necessary to make the surgery easier.

Vocal fold paresis

Vocal fold paresis (VFP) is a relatively common and often overlooked condition that can be difficult to diagnose based on the laryngeal examination alone. A retrospective review of the records of 50 consecutive adult patients with VFP was performed. In each case, the diagnosis of VFP was confirmed by laryngeal electromyography. The presenting symptoms were dysphonia (100%), vocal fatigue (76%), diplophonia (40%), and odynophonia (12%), and the findings were unilateral vocal fold hypomobility (50%), unilateral bowing (36%), and bilateral bowing (22%). Laryngoplasty and/or lipoinjection was performed in 54% of the subjects, and significant vocal improvement was achieved in 85%. VFP appears to be underdiagnosed because many VFP patients have compensatory hyperkinetic disorders at presentation. Although the diagnosis of VFP may be suspected based on the patient's symptoms and findings, the diagnostic sine qua non is laryngeal electromyography. In addition, surgical treatment for VFP appears to be safe and effective.

Advances and refinements in phonosurgery

Scientific discovery, technological advances, and improved outcomes assessment have resulted in advances and refinements in phonosurgery. Three areas of substantial evolution are phonomicrosurgery, laryngeal framework surgery, and the use of implantable materials in vocal folds. Discovery of the importance of the superficial layers of the lamina propria has led to increased use of more limited medial microflap approaches and less frequent use of the classic lateral cordotomy flap approach. Alternative approaches to managing vocal fold scarring defects have addressed the separation of body and cover and provided suitable lamina propria replacement. Approaches to sulcus vocalis have been refined to address type II (linear vergeture) and type III (focal invasive pit) sulcus, where there is loss of lamina propria, while still recognizing the common nonpathological type I (physiological) sulcus. Technological advancements such as photodynamic therapy, tuned dye lasers, and laryngeal microdebridement have augmented the armamentarium for mechanical removal of laryngeal papillomata. Careful infusion-assisted microexcision and adjunctive medical management have been refined and made more effective. Laryngeal framework surgery has embraced the development of Silastic, hydroxylapatite, expanded polytetrafluoroethylene, and titanium shims. Anatomical studies have helped to improve operative precision and safety, and have led to inventive variations in arytenoid repositioning that improve closure of the posterior subunit. Vocal fold augmentation by injection has been facilitated by innovative use of the rigid telescope and intraoperative videostroboscopy. Anatomical studies have focused on the infrafold region and rheological studies have attempted to match viscoelastic properties of injectable substances to those of vocal fold tissues. Alloplastic materials such as Teflon have been largely supplanted by newer bioimplantables such as fat, collagen, and fascia.

Histologic findings of silastic medialization in the canine model

OBJECTIVES

Examine the long-term histological effects of Silastic medialization using a canine model.

STUDY DESIGN

Prospective study evaluating the effects of Silastic medialization in six canine larynges.

METHODS

Two subject groups were evaluated. The first group of four dogs underwent recurrent laryngeal section followed by Silastic medialization on the paralyzed side and placement of a smaller implant on the mobile side. Two of the dogs were sacrificed at 9 months and two at 2 years. The second subject group consisted of two additional dogs who underwent Silastic medialization followed by removal of the implants at 7 months and were sacrificed 18 months later. The larynges were then processed, sectioned in the axial plane, and examined microscopically.

RESULTS

Histological findings of both the mobile and paralyzed sides showed a thin (< 0.5 mm) fibrous capsule surrounding the implant and minimal inflammatory response. Vocal fold mobility was maintained in all cases in which the recurrent laryngeal nerve was left intact. Capsule formation and inflammatory response were similar in all cases.

CONCLUSIONS

Minimal tissue reactivity over a prolonged period of time suggests that long-term results of Silastic medialization remain stable in paralyzed and mobile vocal folds for up to 2 years. Similar tissue response in the subjects in which the Silastic block was removed also suggests that Silastic medialization is a reversible procedure.