Perspectives on voice treatment for unilateral vocal fold paralysis

Experiences with healthcare for unilateral vocal fold paralysis: A qualitative study of the patient's perspective

OBJECTIVE

Unilateral vocal fold paralysis (UVFP) frequently causes severe dysphonia, which necessitates multidisciplinary treatment. Literature on outcomes of interventions has primarily focused on vocal fold motility or instrumental vocal outcomes, but the perspectives of patients about the treatment process have not yet been investigated. The purpose of the study was therefore to explore patient experiences with healthcare for UVFP.

METHODS

Twenty-four adults with UVFP (age range: 39 - 84 years) participated in the study. Semi-structured interviews were conducted, transcribed, and analyzed with the software program NVivo. An inductive thematic approach was used to code and analyze the interviews.

RESULTS

Three themes were identified through the qualitative analyses: (1) the healthcare professional (HCP), (2) experiences with treatment, and (3) patient support. The laryngologist and speech-language pathologist (SLP) were crucial HCPs during treatment, and patients relied heavily on their advice, so they expected them to be knowledgeable about UVFP and empathic towards their patients. Voice therapy was mostly a positive experience due to the collaborative therapeutic relationship with the SLP, even though it did not yield sufficient voice improvements. Medialization surgery was a relief for some participants, while others expected more or felt too vulnerable to undergo surgery. Sources of patient support included personal connections such as relatives and fellow patients, but participants expressed a need for increased support and guidance from the healthcare system.

CONCLUSION

Overall, participants were satisfied with the care that they had received, but certain barriers and needs within UVFP healthcare were identified. The findings from the current study can help guide the development of initiatives to better support patients and HCPs and improve patient-centered care in UVFP.

Prevention and Management of Recurrent Laryngeal Nerve Palsy in Minimally Invasive Esophagectomy: Current Status and Future Perspectives

Recurrent laryngeal nerve palsy remains a significant complication following minimally invasive esophagectomy for esophageal cancer. Despite advancements in surgical techniques and lymphadenectomy precision, the incidence of recurrent laryngeal nerve palsy has not been improved. Recurrent laryngeal nerve palsy predominantly affects the left side and may lead to unilateral or bilateral vocal cord paralysis, resulting in hoarseness, dysphagia, and an increased risk of aspiration pneumonia. While most cases of recurrent laryngeal nerve palsy are temporary and resolve within 6 to 12 months, some patients may experience permanent nerve dysfunction, severely impacting their quality of life. Prevention strategies, such as nerve integrity monitoring, robotic-assisted minimally invasive esophagectomy, and advanced dissection techniques, aim to minimize nerve injury, though their effectiveness varies. The management of recurrent laryngeal nerve palsy includes voice and swallowing rehabilitation, reinnervation techniques, and, in severe cases, surgical interventions such as thyroplasty and intracordal injection. As recurrent laryngeal nerve palsy can lead to significant postoperative respiratory complications, a multidisciplinary approach involving surgical precision, early detection, and comprehensive rehabilitation is crucial to improving patient outcomes and minimizing long-term morbidity in minimally invasive esophagectomy. This review article aims to inform esophageal surgeons and other clinicians about strategies for the prevention and management of recurrent laryngeal nerve palsy in esophagectomy.

Analysis of the Outcomes of Immediate Recurrent Laryngeal Nerve Reconstruction During Thyroid Surgery for Prevention of Vocal Fold Paralysis

BACKGROUND

Recurrent laryngeal nerve (RLN) injury and the resulting paralysis is the most common and known complication of thyroid surgery. Several surgical techniques, such as medialization thyroplasty with or without arytenoid adduction and injection laryngoplasty, have been developed to treat RLN injury, but these procedures have specific limitations and complications. In this study, we present the outcomes for our patients who underwent immediate RLN reconstruction during thyroid surgery by analyzing both subjective and objective outcomes.

METHODS

A retrospective study was conducted for patients who underwent total or subtotal thyroidectomy between May 2012 and March 2020. Among them, patients who underwent immediate RLN reconstruction due to unilateral RLN injury were followed for at least 12 months. The voice perceptual evaluation, acoustic analysis, voice range profile, and Voice Handicap Index (VHI) scores were obtained preoperatively, 1 month, 6 months, and 12 months after surgery.

RESULTS

Among the 11 patients, 6 patients (54.5%) underwent direct anastomosis, and 5 patients (45.5%) underwent nerve grafts using ansa cervicalis and great auricular nerve. The grade and breathiness in the GRBAS (grade, roughness, breathiness, asthenia, and strain) scale and jitter item showed significant improvement at 12 months postoperatively, and although not statistically significant, the rest of the items also tended to improve. The total, functional, and physical scores on VHI improved significantly at 12 months postoperatively. Moreover, when comparing the voice analysis of the direct anastomosis group and the nerve graft group, there was no significant difference between the groups in objective and subjective results.

CONCLUSION

Immediate RLN reconstruction demonstrated significant voice improvement postoperatively, and reconstructing the nerve immediately and combining follow-up treatment in the event of RLN injury will greatly help patients improve their long-term voice outcomes.

Towards modeling of phonation and its recovery in unilateral vocal fold paralysis by fluid-structure interaction

Introduction

Vocal folds are responsible for sound generation. In unilateral vocal fold paralysis (UVFP), the recurrent laryngeal nerve, which controls the vocal folds, is paralyzed. Medialization laryngoplasty is a surgery in which an implant is inserted to push the paralyzed vocal fold to the centerline to recover phonation.

Methods

Here, a numerical simulation is used to calculate flow-related parameters to give insight into what happens in healthy and treated(implanted) vocal folds and their enhancement. In the present work, airflow over vocal folds is modeled considering fluid-structure interaction (FSI) and varying inlet pressure. The governing equations are discretized for fluid and solid domains and solved using the Galerkin finite element method. The boundary conditions for healthy and unilaterally paralyzed vocal folds were imposed to agree with real cases behavior.

Results

The results showed the effectiveness of medialization laryngoplasty in treating unilateral vocal fold paralysis concerning healthy vocal folds.

Conclusion

This simulation provided a better insight into treatment results for patient-specific cases.

Clinical Experiences of Speech-Language Pathologists in the Rehabilitation of Unilateral Vocal Fold Paralysis

PURPOSE

Unilateral vocal fold paralysis (UVFP) is a neurological voice disorder that is often first treated by a speech-language pathologist (SLP). In literature, little consensus is found regarding voice therapy onset, duration, frequency, and content. The aim of the current study is to investigate the clinical practice of SLPs for treatment of UVFP regarding diagnostics and treatment characteristics. Additionally, the study examined the personal experiences of SLPs regarding UVFP care.

METHOD

An online survey was completed by 37 respondents, all SLPs with experience in treating UVFP. Demographic characteristics, experiences with voice assessments and treatment modalities were examined. Lastly, experiences and opinions of SLPs on evidence-based practice and their own clinical practice were surveyed.

RESULTS

Almost all respondents used a multidimensional voice assessment with findings from laryngovideostroboscopy to assess UVFP. Laryngeal electromyography is not yet integrated in regular clinical practices. The most commonly used vocal techniques were resonant voice exercises, laryngeal manipulation, semioccluded vocal tract exercises (SOVTEs), vocal hygiene, and Vocal Function Exercises, with SOVTEs most often considered effective. A total of 75% of the respondents feel confident treating UVFP, and 87.6% believe it is important to stay updated on evidence-based practice. Variation in therapy timing and dosage was observed, and 48.4% of SLPs usually started early voice therapy within 4 weeks after UVFP onset.

CONCLUSION

Flemish SLPs generally feel confident treating UVFP patients and show interest in improving evidence-based practice. Initiatives to train clinicians further in UVFP care and encouraging SLPs to provide practice-based evidence will enhance the knowledge base for evidence-based practice in UFVP.

Inducible Laryngeal Obstruction Differential Diagnosis in Adolescents and Adults: A Tutorial

Inducible laryngeal obstruction (ILO), formerly referred to as paradoxical vocal fold motion and vocal cord dysfunction, is a complex disorder of the upper airway that requires skillful differential diagnosis. There are several medical conditions that may mimic ILO (or which ILO may mimic) that should be considered in the differential diagnosis before evidence-supported behavioral intervention is initiated to mitigate or eliminate this upper airway condition. A key in treatment planning is determination of an isolated presentation of ILO or ILO concurrent with other conditions that affect the upper airway. Accurate, timely differential diagnosis in the clinical assessment of this condition mitigates delay of targeted symptom relief and/or insufficient intervention. Accurate assessment and nuanced clinical counseling are necessary to untangle concurrent, competing conditions in a single patient. This tutorial describes the common and rare mimics that may be encountered by medical professionals who evaluate and treat ILO, with particular attention to the role of the speech-language pathologist. Speech-language pathologists receive referrals for ILO from several different medical specialists (allergy, pulmonology, and sports medicine), sometimes without a comprehensive team assessment. It is paramount that speech-language pathologists who assess and treat this disorder have a solid understanding of the conditions that may mimic ILO. Summary tables that delineate differential diagnosis considerations for airway noise, origin of noise, symptoms, triggers, role of the speech-language pathologist, and β-agonist response are included for clinician reference. A clinical checklist is also provided to aid clinicians in the critical assessment process.

Demographic differences in the treatment of unilateral vocal fold paralysis

Objective

To determine the impact of patient demographics and social determinants of health on treatment pathways for unilateral vocal fold paralysis (UVFP) at a tertiary laryngology clinic.

Study design

Retrospective medical record review.

Methods

Patient demographics (age, gender, race, ethnicity, and insurance status) were extracted for adults diagnosed with UVFP between 2009 and 2019. Odds ratios for the associations between sociodemographic factors and UVFP treatment pathways were determined by chi-square analyses.

Results

A total of 1490 UVFP diagnoses were identified during the study period with the majority being female (58%), White (85%), non-Hispanic (97%), and publicly insured (54%). Five treatment pathways were identified: observation, injection laryngoplasty, voice therapy, laryngeal framework surgery/thyroplasty, and reinnervation surgery. There were 538 patients who underwent observation, 512 injection laryngoplasty, 366 voice therapy, 136 thyroplasty, and 26 laryngeal reinnervation surgery. Males were more likely to undergo injection laryngoplasty than females (OR 1.32; CI 1.08-1.61), whereas females were more likely to undergo voice therapy (OR 1.39; CI 1.09-1.76). Patients with public insurance (OR 1.48; CI 1.03-2.14) and Hispanics (OR 2.60; CI 1.18-5.72) were more likely to undergo thyroplasty. Patients who underwent reinnervation surgery were younger than those in other treatment pathways (median: 39.1 years vs. 50.7-56.1 years).

Conclusions

Gender, ethnicity, and insurance status were significantly associated with specific UVFP treatment pathways. Patients with public insurance were more likely to undergo surgical intervention than voice therapy. This data overall supports differences in care pathway utilization for UVFP based on social determinants of health.

Level of evidence

Level IV.

Comparison of 24-month voice outcomes after injection laryngoplasty with calcium hydroxylapatite or hyaluronic acid in patients with unilateral vocal fold paralysis

PURPOSE

The objective was to evaluate the long-term voice outcomes in pa-tients with unilateral vocal fold paralysis treated with injection laryngoplasty using either cal-cium hydroxylapatite (CaHA) or hyaluronic acid (HA).

METHODS

A single-centre retrospective study was performed. There were 75 patients with dysphonia due to unilateral vocal fold paralysis: injected with CaHA or injected with HA. We analysed Voice Handicap Index-30 (VHI), videostroboscopic images, auditory-perceptual (GRBAS), and acoustic measures (MDVP) in 6, 12, and 24 months after augmentation.

RESULTS

The mean change in VHI 24 months after augmentation was 29.14 in the CaHA group, and 22.88 in the HA group. There was an improvement of glottal gap 6, 12, and 24 months after augmentation in both groups. The GRBAS parameters were similar in both groups throughout the whole period. The MDVP pa-rameters decreased 6 and 12 months after augmentation and were similar in both groups. There were 4 patients augmented with CaHA (12.5%) who needed reintervention within 2 years of surgery and another 4 (9.3%) augmented with HA.

CONCLUSION

This study demonstrates that there are no long-term differences in voice outcomes or number of reaugmentations for injection laryn-goplasty with CaHA compared to HA.

Modified Arytenoid Adduction Operation for the Treatment of Unilateral Vocal Fold Paralysis

INTRODUCTION

Unilateral vocal fold paralysis (UVFP) was a relative common glottic insufficiency disease; however, a completely satisfactory treatment of UVFP was elusive. This study was aimed to evaluate the surgical efficacy of modified arytenoid adduction with fenestration of the thyroid cartilage in the management of patients with UVFP, including voice and aspiration outcomes, and to summarize the postoperative complications.

METHODS

A retrospective analysis was performed on a total of 21 patients who underwent modified arytenoid adduction operation with fenestration of the thyroid cartilage for UVFP from July 2012 to June 2017. The scores of Grade, Roughness, Breathiness, Asthenia, Strain scale (GRBAS), voice self-satisfaction, dynamic laryngoscopy and the voice acoustic data (fundamental frequency [F0], fundamental frequency perturbation [jitter], loudness, amplitude perturbation [shimmer], and maximal phonatory time [MPT], etc.) were statistically analyzed preoperatively and 3-6 months postoperatively. The occurrence of postoperative complications was also summarized.

RESULTS

The voice subjective perception of 21 patients was significantly improved after operation. The rate of voice self-satisfaction was 90.5%. The mean values of voice acoustics parameters were significantly improved. The MPT was significantly longer (p < 0.001), and the ratings of postoperative aspiration were significantly decreased compared with the preoperation. Among the 21 patients, 15 cases had sense of laryngeal obstruction, 8 cases had of 1-2° laryngemphraxis (recovered after 10-15 days). There were 2 cases of laryngeal stridor, 1 case of incision infection, 1 case of pharyngeal fistula, and 1 case of falsetto (corrected by voice training). No patient had laryngeal hematoma, neck hematoma, or laryngospasm.

CONCLUSION

The modified arytenoid adduction operation with fenestration of the thyroid cartilage can significantly improve the vocal function of patients with UVFP and effectively reduce the aspiration, with fewer postoperative complications, less trauma, and more convenient advantages.

Can preoperative results predict the need for future reintervention following injection laryngoplasty for unilateral vocal fold paralysis?

Purpose

The objective was to investigate whether a patient’s preoperative test results can predict the need for future reoperation in unilateral vocal fold paralysis (UVFP).

Methods

A single-centre retrospective study was performed. The study group consisted of 18 patients with UVFP who had been treated with injection laryngoplasty but who required further treatment and were augmentated again within 36 months. The control group consisted of 33 injected patients who had not required reintervention up to 36 months later.

Results

Only glottal gap was associated with a relative risk for reinjection. Glottal gap was found to be severe in 77.8% of the patients from the study group compared to 42.4% of the controls, and the difference was statistically significant. The kind of injected material (calcium hydroxylapatite or hyaluronic acid), age, and voice assessment (perceptual, objective, or subjective) did not seem to affect the likelihood of reoperation being needed. There were no between-group statistically significant differences in individual aspects of the GRBAS scale. The global score was slightly higher in the study group, but it did not reach statistical significance (U = 198.5; p = 0.09). A comparison of VHI scores did not yield statistically significant differences between the study and control groups. No significant differences in objective acoustic voice parameters were observed between the groups.

Conclusion

Only glottal gap occurred to be associated with a relative risk for reinjection. A kind of injected material (CaHA or HA), age, perceptual, objective and subjective voice assessment do not seem to impact the likelihood of reoperation in patients with UVFP.

Vocal fold injection material does not preclude interpretation of laryngeal electromyography

INTRODUCTION/AIMS

Temporary vocal fold injection (VFI) is a common treatment for acute and subacute vocal fold paralysis (VFP). Laryngeal electromyography (LEMG) is useful for diagnosing neurogenic causes of VFP. This study evaluated whether the presence of VFI material prevents interpretation of LEMG in patients with acute and subacute VFP.

METHODS

Patients with acute and subacute unilateral VFP (onset ≤6 mo) who underwent temporary VFI within 3 mo preceding LEMG were evaluated. A matched control group that did not undergo VFI was also studied. The LEMG team (laryngologist and electromyographer) performed and interpreted LEMG using a pre-specified protocol, including qualitative and quantitative motor unit analysis.

RESULTS

Eighteen patients with VFI underwent LEMG successfully with interpretation of spontaneous activity and motor unit recruitment. Fourteen patients were seen in follow-up to determine accuracy of established LEMG prognosis. Seven of seven subjects with poor LEMG prognosis did not recover vocal fold motion. Five of seven subjects with fair LEMG prognosis recovered vocal fold motion. Findings were similar for the control group.

DISCUSSION

VFI augmentation material did not prevent interpretation of meaningful LEMG data in patients with acute and subacute VFP, and accurate prognoses of vocal fold motion recovery were established.

Applicability of Selective Electrical Surface Stimulation in Unilateral Vocal Fold Paralysis

OBJECTIVE

Selective electrical surface stimulation (SES) of the larynx is not yet routinely considered therapy option in treatment of unilateral vocal fold paralysis (UVFP). Goal of this monocentric feasibility study was to provide systematic data on applicability of SES of intrinsic laryngeal muscles in UVFP under consideration of sensitivity and discomfort thresholds and nonselective side effects.

METHODS

Thirty-two UVFP patients were included in the study. Symmetric triangular-shape, charge-balanced pulse widths (PWs) of 1, 10, 25, 50, 100, 250, and 500 milliseconds (ms) were tested with increasing amplitudes (AMPs). The stimulation was delivered as a train of five pulses using square surface electrodes. Selective laryngeal responses were examined by flexible laryngoscopy. Nonselective side effects (swallowing reflex, coughing, different severity degrees of unspecific strap muscle/platysma response) were judged by observation.

RESULTS

Selective laryngeal response could be triggered in 28/32 (87.5%) patients during respiration/rest and in 26/32 (81.3%) patients during phonation. The most effective PWs for the selective eliciting of selective bilateral vocal fold adduction are comprised between 50 and 100 ms in combination with an average AMP comprised between 7.1 and 7.2 mA.

CONCLUSION

Our results indicate that, in UVFP patients, PWs comprised between 50 and 100 ms in combination with a median AMP between 7.1 and 7.2 mA are expected to deliver in >75% of the cases a specific, effective, and safe bilateral adduction of the VF.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2566-E2572, 2021.

Comparison of voice therapy and selective electrical stimulation of the larynx in early unilateral vocal fold paralysis after thyroid surgery: A retrospective data analysis

Objectives

The goal of the retrospective study was to investigate the 3‐month‐outcome after treatment of patients with early unilateral vocal fold paralysis (UVFP) with either standard voice therapy (VT) or selective electrical stimulation of the larynx (SES).

Design

Non‐randomised retrospective study.

Setting

1519 patients who underwent thyroid surgery between 2015 and 2018 were analysed according vocal fold mobility; UVFP patients were treated either by VT or SES.

Participants

51 UVFP patients.

Main outcome measures

51 UVFP patients have been advised regarding treatment options like either VT (group 1) or SES (group 2). The patients of group 1 (n = 26) and 2 (n = 25) were re‐assessed up to 3 months post‐operatively regarding UVFP persistence/recovery and perceptive voice sound quality. At follow‐ups, perceptual analysis of voice sound (using roughness=R/breathiness=B/hoarseness=H scale) and endoscopic laryngoscopy have been performed. Position of immobile vocal fold, shape of glottal closure and RBH parameters have been considered for statistical analyses.

Results

Restitution of UVFP with regular respiratory vocal fold mobility of both vocal folds occurred in 53.8% of group 1 (VT), and in 40.0% of group 2 (SES) after 3 months of therapy between both groups. No difference could be seen for RBH, type of glottal closure and position of ailing vocal folds in patients with persisting UVFP within both groups and between the groups.

Conclusions

The study reveals that SES can achieve similar functional outcome in early UVFP. Thus, it should be considered as an equivalent therapy alternative to VT for treatment of early UVFP patients since no significant difference in vocal outcome and glottal configuration between the two groups could be demonstrated.

Rehabilitation Therapy for Vocal Fold Paralysis Caused by Lung Cancer: A Case Report

OBJECTIVE

Unilateral vocal fold paralysis (UVFP) can be caused by iatrogenic injury or tumor-induced damage to the recurrent laryngeal nerve. Studies of comprehensive rehabilitation therapies for patients suffering from severe UVFP are limited. The purpose of this case report is to describe an improvement in complete aphonia after comprehensive rehabilitation therapies in a patient with severe UVFP due to a lung tumor.

METHODS

An 81-year-old woman with a history of bronchial adenoma had complete aphonia due to compression of the left recurrent laryngeal nerve by the tumor. Dynamic fibrolaryngoscope revealed paralysis of the left vocal fold. The patient was treated with interferential current therapy, vocal training, and kinesiology taping. Indicators of voice recovery were scored according to the grade, roughness, breathiness, asthenia, strain scale, and the voice handicap index.

RESULTS

After 10 days of comprehensive rehabilitation treatment, the patient recovered from complete aphonia to normal communication. The hoarseness and breathiness of patient were significantly improved. In addition, the grade, roughness, breathiness, asthenia, strain, and the voice handicap index scores changed from severe to mild or absent.

CONCLUSION

This case provided a novel comprehensive treatment for a patient with UVFP, which was safe, cost-effective, and easy to implement in clinic.

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.

Epidemiological Patterns and Treatment Outcomes in a Private Practice Community Voice Clinic

OBJECTIVES

Voice therapy is administered by speech-language pathologists in multiple practice settings, including private practice community voice clinics. However, the evidence for diagnosis patterns and voice treatment outcomes in community voice clinics is very limited. The purpose of this study was to extend knowledge from a previous investigation by assessing the epidemiological patterns of patient referrals to a private practice community voice clinic across a 4-year period (50 months) and to measure the effectiveness of treatment outcomes for patients who were followed up with voice therapy in the same setting.

STUDY DESIGN

Retrospective case series.

METHODS

Consecutive patient records from November 2014 through January 2019 were reviewed. Patients were grouped into seven categories of distinctive diagnoses. Descriptive data for each group were extracted to determine epidemiological patterns of disorder diagnosis, voice handicap, voice quality severity, age, and gender. For patients who completed at least three treatment sessions, pre- and posttreatment measurements of two assessments, the Voice Handicap Index (VHI) and the Acoustic Voice Quality Index (AVQI), were extracted and compared using a multivariate analysis of variance.

RESULTS

Records from 454 consecutive patient referrals over a 50-month time period were reviewed. The most frequent diagnoses were multifactorial etiologies or those with only a few cases, categorized collectively as an "other" diagnosis category. Diagnoses of nonspecific dysphonia and mid-membranous lesions were also common. Consensus Auditory Perceptual Evaluation of Voice-scale scores were not different among disorders; however, group differences were found for VHI and AVQI. Treatment data were available for 292 patients, with 47 of those patients completing at least three treatment sessions and with data for pre- and posttreatment VHI and AVQI. A mixed multivariate analysis of variance showed a significant effect of treatment (Wilks' Lambda = 0.42, F[2] = 27.58, P < 0.001, ƞ_p² = 0.58), where both AVQI and VHI improved significantly across the pre- to posttreatment measurements.

CONCLUSIONS

Patient characteristics and diagnosis patterns across a 50-month period were similar when compared to a previous study that investigated epidemiological patterns in this clinic across 28 months. Voice therapy administered in this community voice clinic to patients with varied diagnoses was found to be effective based on changes in VHI and AVQI measurements.

Speech Pathology Utilization and Stroboscopy Before and After Adult Medialization Laryngoplasty

OBJECTIVES

Evaluation of trends and utilization of speech-language-pathology (SLP) services, including stroboscopy, before and after medialization laryngoplasty (ML) over 11 years.

METHODS

Retrospective national US database study conducted using OptumLabs Data Warehouse. Study cohort included patients (age ≥18 years) who underwent ML between January 2007 and December 2016. Primary outcomes were rates of SLP visits in the 12 months before and 12 months after ML. Linear regression analysis was performed assessing for trends utilization across years. Secondary outcomes were predictors of utilization After-ML using multivariable logistic regression.

RESULTS

1114 patients met criteria. Services, including stroboscopy, were utilized by 774 (69%) Before-ML and 697 (63%) After-ML. SLP services, excluding stroboscopy, were utilized by 512 (46%) Before-ML and 478 (43%) After-ML. Vocal cord paralysis was the most common diagnosis, 945 (84.8%) patients. Other service billed were stroboscopy, [Before-ML 676 (60.7%); After-ML 567 (50.9%)], voice evaluation [Before-ML 431(38.7%); After-ML 366 (32.9%)], voice therapy [Before-ML 309 (27.7%); After-ML 339 (30.4%)], laryngeal function studies, [Before-ML 175 (15.7%); After-ML 164 (14.7%)], swallow evaluations [Before-ML 150 (13.5%); After-ML 90 (8.1%)], and swallow therapy [Before-ML 53 (4.8%); After-ML 47 (4.2%)]. SLP utilization Before-ML predicted SLP utilization After-ML [Odds Ratio (95% Confidence Interval): 9.31 (6.78, 12.77)]. Nearly half (49%) of visits occurred in the 6 months around ML. Of those who had voice therapy, the majority (73.7%) had a total of 1 to 5 sessions.

CONCLUSION

Based on this retrospective US national database study, SLP services and stroboscopy are a complementary component of assessment and treatment of patients who undergo ML with the majority of services occurring in the 3 months before and after ML. Future work would benefit from outcome data.

Treatment Efficacy of Voice Therapy Following Injection Laryngoplasty for Unilateral Vocal Fold Paralysis

OBJECTIVES

Injection laryngoplasty (IL) is performed to reduce the gap between vocal folds induced by unilateral vocal fold paralysis (UVFP). Voice quality after IL may be different due to other factors that influence voice quality. Voice therapy has been reported to improve voice quality after IL in patients with UVFP. This study evaluated the efficacy of voice therapy combined with IL.

METHODS

Patients with UVFP who underwent IL as primary therapy from March 2017 to June 2019 were evaluated. The enrolled patients were divided into two groups, those who did and did not receive voice therapy after IL. Voice quality was evaluated using perceptual, acoustic, and aerodynamic parameters, and voice handicap index-30 scores one month after IL and after completing each treatment.

RESULTS

Of 261 patients who underwent IL during the study period, 40 were enrolled, including 21 who did and 19 who did not receive voice therapy. Voice parameters one month after IL did not differ between these two groups. Jitter, shimmer, noise-to-harmonic ratio, and mean flow rate decreased, while maximum phonation time increased after voice therapy (both P < 0.05). In the absence of voice therapy, improved voice parameters were maintained for six months after IL. Total voice handicap index-30 scores decreased, from 35.6 to 19.1 (P < 0.05), in patients who received voice therapy.

CONCLUSION

Voice therapy following IL is beneficial to patients with UVFP. Combined treatment can help to maintain improved voice quality more than six months after IL.

Autologous Fat Augmentation in the Treatment of Unilateral Vocal Fold Paralysis - A 15-year Experience in a Single Institution

Autologous fat vocal fold augmentation is a widespread surgical procedure that aims to repair glottal incompetence in patients with unilateral vocal fold paralysis (UVFP). However, there are some concerns in the literature about the long-term results of this technique. At the ENT Department of the Zagreb University Hospital Centre, this technique has been in use for more than 15 years, and a retrospective medical chart review was conducted from June 2005 to November 2019. Overall, 78 patients with UVFP met the inclusion criteria for enrolment in the study. All patients underwent at least one preoperative and two postoperative voice assessments, one early (within 3 months from surgery) and one late (at least 1 year after surgery). All tested voice outcome parameters (maximum phonation time (MPT), jitter, shimmer, noise-to-harmonic ratio (NHR)) significantly improved after surgery, both early and late postoperatively (p<0.001). The reoperation rate was only 10.3% (8/78), with the majority of patients in our series experiencing long-term benefits from this surgical procedure. According to the results of our study, autologous fat vocal fold augmentation appears to be a highly useful and effective surgical technique with long-lasting results in the majority of patients suffering from UVFP.

The surgical treatment of unilateral vocal cord paralysis (UVCP): qualitative review analysis and meta-analysis study

PURPOSE

The objectives of this meta-analysis were to summarize the key surgical procedures for UVCP and to evaluate which of these is associated with better results in terms of vocal improvement.

METHODS

A systematic review of the literature was conducted in search of articles focused on the comparison of voice outcome between different techniques for the UVCP treatment. Then, a quantitative analysis was carried out for papers published from 2013 onwards, reporting only adult patients with unilateral paralysis for each study, and each surgical technique was evaluated for its capability of achieving good functional outcomes in terms of GRBAS-I scale and maximum phonation time in seconds (MPT).

RESULTS

The search identified 1853 publications. A total of 159 articles were stratified and included according to our selection criteria. 21 out of 159 articles were selected for quantitative synthesis. For trans-oral techniques: the mean GRBAS-I scale were 2.33 before injection and 0.41 after injection. The mean MPT before injection were 4.78 and 12.50 after injection. For open techniques the mean GRBAS-I scale were 2.43 before surgery and 0.68 after surgery. For open technique, the mean MPT were 3.50 before surgery and 12.40 after surgery.

CONCLUSIONS

The two types of techniques lead to an improvement in terms of vocal outcomes emphasizing that from the examined literature an indication emerges to perform an early injection because this could reduce the possible need for a more invasive intervention of permanent medialization in the future.

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.