Lack of Adverse Events after Medialization Laryngoplasty with the Montgomery Thyroplasty Implant in Patients with Unilateral Laryngeal Nerve Paralysis

Objectives:

We sought to document the incidence of and risk factors for adverse events after medialization laryngoplasty with Montgomery implant insertion in patients with unilateral laryngeal nerve paralysis.

Methods:

We studied a retrospective series of 191 patients consecutively managed at a university teaching hospital.

Results:

No adverse events were noted in 79.8% of the patients. Intraoperative, immediate, and late postoperative adverse events were noted in 8.3%, 8.9%, and 4.1% of the patients, respectively. The various adverse events noted were failure to insert the implant (3.6%), difficulties in stabilizing the implant (4.8%), misplacement of the implant (2.1%), dyspnea (2.7%), hematoma (4.8%), extrusion (1.6%), persistent morphological laryngeal alterations (1.6%), and keloid scars (1.1%). Tracheotomy, procedure-related death, and infection at the insertion site were not encountered. No significant statistical relationship was noted between the various adverse events encountered and the variables under analysis.

Conclusions:

Our data demonstrate that medialization laryngoplasty with Montgomery implant insertion in patients with unilateral laryngeal nerve paralysis from various causes is a relatively safe, reliable, and reproducible procedure with a short learning curve.

Use of rhinomanometry in common rhinologic disorders

Rhinomanometry is a functional test of nasal aerodynamics that measures transnasal airflow and the pressure gradient allowing nasal resistance to be calculated from these data. Three methods of rhinomanometry that are currently in use are anterior rhinomanometry, posterior (peroral) rhinomanometry and postnasal (pernasal) rhinomanometry. The usefulness of this method has increased owing to the development of technology and use of microcomputers connected to the measuring devices. Rhinomanometry can be used for: clinical evaluation of the symptom of nasal obstruction; research in nasal physiology; allergy challenge testing; pre- and post-treatment assessments of surgical or medical therapy; and evaluation of patients with sleep apnea.

Systematic Review of Endoscopic Airway Findings in Children with Gastroesophageal Reflux Disease

Objectives:

We performed a systematic review of published literature correlating findings on endoscopic evaluation of the larynx and trachea in the pediatric population with the incidence of gastroesophageal reflux disease.

Methods:

Eight articles were identified through a structured PubMed search of English-language literature using the key terms laryngopharyngeal reflux, extraesophageal reflux, and gastroesophageal reflux. A systematic review was performed relating the presence of reflux in the pediatric population to findings on endoscopic airway evaluation. A covariant analysis was performed, and each study was weighted according to the number of available samples in that study as a fraction of the total. Overall odds ratios and confidence intervals were computed for each endoscopic finding on the basis of the documented absence or presence of gastroesophageal reflux disease.

Results:

A correlation was seen between the endoscopic findings and the presence of reflux.

Conclusions:

Arytenoid, postglottic, and vocal fold edema and erythema, lingual tonsil hypertrophy, laryngomalacia, and subglottic stenosis are among the endoscopic findings most frequently identified in patients with gastroesophageal reflux disease. Certain findings commonly encountered on endoscopic evaluation of the larynx and trachea in children who present with respiratory symptoms do indeed demonstrate a correlation with the presence of laryngopharyngeal reflux disease and may indicate the need for antireflux therapy.

Multiparameter analysis of titanium vocal fold medializing implant in an excised larynx model

OBJECTIVES

We evaluated the efficacy of the titanium vocal fold medializing implant (TVFMI) for the treatment of unilateral vocal fold paralysis (UVFP) on the basis of acoustic, aerodynamic, and mucosal wave measurements in an excised larynx setup.

METHODS

Measurements were recorded on 8 excised canine larynges with simulated UVFP before and after medialization with a TVFMI.

RESULTS

The phonation threshold flow (p < 0.001) and phonation threshold power (p = 0.008) decreased significantly after medialization. The phonation threshold pressure also decreased, but this difference was not significant (p = 0.081). Jitter (p = 0.005) and shimmer (p = 0.034) decreased significantly after medialization. The signal-to-noise ratio increased significantly (p = 0.05). Differences in mucosal wave characteristics were discernible but not significant. The phase difference between the normal and paralyzed vocal folds (p = 0.15) and the amplitude of the paralyzed vocal fold (p = 0.78) decreased. The glottal gap decreased significantly (p = 0.004).

CONCLUSIONS

The TVFMI was effective in achieving vocal fold medialization, improving vocal aerodynamic and acoustic characteristics of phonation significantly and mucosal wave characteristics discernibly. This study provides objective, quantitative support for the use of the TVFMI in improving vocal function in patients with UVFP.

Long-Term Acoustic Comparison of Thyroplasty versus Autologous Fat Injection

Objectives:

Medialization by thyroplasty or intracordal autologous fat injection provides voice improvement in patients with unilateral vocal fold paralysis. Thyroplasty is considered a “permanent” medialization, whereas fat injection is considered “temporary” because of reabsorption. The objective of this study was to compare the evolution of acoustic parameters for these procedures over 1 year and to evaluate the results of fat injection at 2 years.

Methods:

From 1994 to 1998, 46 consecutive patients (17 women and 29 men) were treated exclusively by intracordal injection of autologous fat, and then from 1999 to 2002, 48 consecutive patients (19 women and 29 men) were treated with the Montgomery Thyroplasty Implant System or Gore-Tex thyroplasty. Each patient's voice was prospectively recorded before operation and at 1, 3, 12, and 24 months after operation. Six patients (13%) in the injection group underwent a second injection, and 1 patient (2%) in the thyroplasty group underwent revision surgery. Jitter, shimmer, and noise-to-harmonics ratio (NHR) were calculated for a 1,000-ms midvowel segment of the vowel / a/.

Results:

One month after operation, jitter, shimmer, and NHR were significantly improved in both groups (Wilcoxon's test, p < 0.05 in all cases). Jitter and shimmer did not change significantly between 1 and 3 months or between 1 and 12 months (p > 0.05). The NHR had improved at 12 months in both groups (injection, p = 0.0004; thyroplasty, p = 0.0178) and at 24 months in the injection group (p = 0.0076). No significant difference was noted between the two techniques before operation or at 1, 3, or 12 months after operation (Mann-Whitney test, p > 0.05). Jitter and shimmer had not changed significantly after 24 months in either group. At 24 months, there was no difference in acoustic parameters between the two treatment groups.

Conclusions:

The two techniques provided comparable objective acoustic voice improvement. At 2 years, autologous fat injection provides long-term acoustic voice improvement comparable to that of thyroplasty, but it has a higher rate of revision surgery.

Thyroplasty Type I With Montgomery Implant among Native French Language Speakers with Unilateral Laryngeal Nerve Paralysis

OBJECTIVE

To document the long-term results achieved with the Montgomery implant in 96 French speakers with a unilateral laryngeal nerve paralysis (ULNP).

STUDY DESIGN

Retrospective series, inception cohort of 96 patients.

METHODS

Data regarding morbidity and functional results were obtained at regular visits to our clinic. All patients were followed for a minimum of 6 months or until death. Forty-two patients had a minimum of 12 months of follow-up. Early in the study, 36 patients were prospectively recorded under similar conditions before placement of the Montgomery implant and at 1, 3, 6, and 12 months postoperatively.

RESULTS

None of the 96 patients died in the immediate postoperative period. The perioperative course was unremarkable in 94.8% of cases. Perioperative problems included failure to obtain a satisfactory phonatory result in three patients, difficulty to stabilize the implant posteriorly in one patient, and fracture of the inferior rim of the thyroid cartilage window in another patient. The primary immediate postoperative problem (within the first postoperative month) was laryngeal dyspnea, noted in four patients. According to the patient's subjective assessment, speech and voice was always improved in the immediate postoperative period. However, three patients had secondary degradation of speech and voice. Revision surgery under local anesthesia resulted in a 97.9% ultimate speech and voice success rate. According to the patient's subjective assessment, adequate swallowing in the immediate postoperative period was achieved in 94.2% of cases that had swallowing problems preoperatively. A significant statistical increase in the duration parameters (phonation time, phrase grouping, speech rate) together with a statistical significant decrease in both the jitter and shimmer values was noted when comparing the preoperative and the postoperative values at 1 month. Analysis of the evolution of the speech and voice parameters at 1, 3, 6, and 12 months postoperatively showed a significant decrease in the fundamental frequency and noise-to-harmonic ratio values but did not demonstrate any significant differences for the other speech and voice parameters.

CONCLUSIONS

From the reported data, we conclude that the type I thyroplasty with Montgomery implant insertion is a safe and reproducible method to treat ULNP. Furthermore, this system achieves very good and stable phonatory results. Finally, the use of this technique and implant system appears safe in patients from various cultures with ULNP from a variety of causes and severe comorbidity. Over the past decade at our department, this procedure progressively replaced the use of the intracordal injection of autologous fat injection that was initially advocated in patients with ULNP.

Nerve-muscle transplantation to the paraglottic space after resection of recurrent laryngeal nerve

OBJECTIVE

To evaluate a new method of nerve-muscle transplantation (NMT) to the paraglottic space after resection of the recurrent laryngeal nerve (RLN) during surgery for thyroid cancer.

DESIGN

Review of nine consecutive patients with RLN paralysis caused by the thyroid cancer before surgery.

METHOD

After the usual extirpation of the thyroid cancer with concomitant removal of the RLN, the lower part of the sternohyoid muscle approximately 1 cm in width and 2 cm in length with the ansa cervicalis nerve connected was inserted into the paraglottic space by way of anterior retraction of the thyroid ala with the inferior horn cut off. When the muscle or the nerve was adhesive to the cancer, the nerve-muscle on the opposite side was used with transfer through the space under the thyrohyoid muscles and the superior horn of thyroid ala.

RESULTS

The voice quality was good or fair after surgery. In most patients, the maximum phonation time was 10 seconds or longer, and the mean flow rate was lower than 200 mL/s. The vocal functions were good immediately after surgery and maintained good values for 2 years or more after surgery. Vocal fold atrophy was not found in any patient.

CONCLUSION

When the RLN is resected during surgery for thyroid cancer end-to-end anastomosis of the nerve is impossible, NMT to the paraglottic space is a useful method for preserving good voice and preventing atrophy of the vocal fold.

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.

Laryngopharyngeal reflux and laryngeal web formation in patients with pediatric recurrent respiratory papillomas

OBJECTIVE

To determine whether treatment of laryngopharyngeal reflux reduces the laryngeal soft tissue complications encountered in surgery for recurrent respiratory papillomas.

STUDY DESIGN

Retrospective chart review.

METHODS

Retrospective chart review of all pediatric patients treated for laryngeal recurrent respiratory papillomas between 1984 and 1999 was performed. Thirty-one such patients were identified. Twenty-four were at "high risk" for developing complications based on the number of operating suite visits and the presence of disease at the anterior commissure. Twelve patients underwent 24-hour double pH probe testing.

RESULTS

Overall, 13 of 31 patients (42%) developed laryngeal webs. No other soft tissue complications were encountered. Of the patients who had pH probe testing, 12 of 12 (100%) had at least one pharyngeal episode of acid exposure. Of the "high-risk" patients, 10 were treated for reflux and only 2 of 10 (20%) developed webs. Eleven of 14 (79%) of the "high-risk" patients who were not treated for reflux developed webs. The difference in rate of web formation between patients treated for reflux and those not treated for reflux was statistically significant (P =.011).

CONCLUSIONS

Antireflux treatments for patients undergoing surgery for laryngeal recurrent respiratory papillomas may reduce the soft tissue complications, especially scarring and web formation. Prophylactic antireflux therapy may be warranted in any patient undergoing surgery during which laryngeal mucosal disruption is anticipated.

A new paramedian approach to arytenoid adduction and strap muscle transposition for vocal fold medialization

OBJECTIVE

To develop a prosthesis-free medialization laryngoplasty for the treatment of glottal incompetence.

STUDY DESIGN

Twenty-two consecutive patients with glottal incompetence underwent vocal fold medialization using a new paramedian approach to arytenoid adduction and/or strap muscle transposition.

METHODS

Under local anesthesia, the thyroid lamina on the involved side was parasagittally separated 5 mm off the midline. The inner perichondrium was carefully freed from the overlying thyroid cartilage. After dividing the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally, the inner perichondrium was opened, and the lateral cricoarytenoid muscle identified. Tracing the muscle fibers posterosuperiorly, the muscular process of the arytenoid was identified. A 2-0 or 3-0 Prolene suture was placed through the muscular process and tied to the cricoid cartilage at the origin of the lateral cricoarytenoid muscle. A bipedicled strap muscle flap was then transposed into the space between the lamina and the inner perichondrium and the thyroid cartilages sutured back into place. Pre- and postoperative voice evaluations measured mean fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, and maximal phonation time, as well as assessments of voice quality.

RESULTS

Vocal improvement was obtained in 95% (21 of 22) of patients. There was a significant improvement (P <.05) in all parameters except shimmer. No major complications were noted in any patient, except for dyspnea in one patient resulting from arytenoid overrotation.

CONCLUSION

The results suggest that a paramedian approach to arytenoid adduction combined with strap muscle transposition is a safe and effective method for treating glottal incompetence, particularly in patients with unilateral paralytic dysphonia.

Evaluation of nasal cavity by acoustic rhinometry in Chinese, Malay and Indian ethnic groups

Acoustic rhinometry (AR) evaluates the geometry of the nasal cavity by measuring the minimum cross-sectional area (MCA) and nasal volume (V) by means of acoustic reflection. Understanding the normal and pathologic conditions of the internal nasal cavity using AR is important in the diagnosis of structural abnormalities in patients. The aim of this study was to investigate the normal range of AR parameters in healthy volunteers from three ethnic groups in Singapore: Chinese, Malay and Indian. We also attempted to evaluate the role of these measurements in the documentation of structural abnormalities in the nose. A total of 189 Singaporeans, aged > or = 18 years, were recruited from a nationwide survey study. They comprised 83 Chinese, 35 Malays and 71 Indians. Eighty-nine subjects had a rhinoscopically normal nose (Group 1), 77 had significant septal deviation (Group 2) and 23 had inferior turbinate hypertrophy (Group 3). AR was performed to measure the MCA at the anterior 1-5 cm from the nostril and the volume (V) between points at the nostril and 5 cm into the nose. A mean MCA (mMCA; equal to (L + R)/2) and a total volume (Vt; equal to L + R) were then calculated for each subject, where L and R refer to the measurements made for the left and right nostrils, respectively. The results showed that there was no statistically significant difference in mMCA (p = 0.80) and Vt (p = 0.60) among the three ethnic subgroups of Group 1. Statistically significant differences were found only between Groups 1 and 3 (p < 0.001 for both mMCA and Vt) and between Groups 2 and 3 (p = 0.001 for mMCA and p = 0.013 for Vt). Although there was no significant difference between Groups 1 and 2, significant differences in MCA (p = 0.001) and V (p = 0.040) were found between the narrower sides (smaller volume) and the wider sides in Group 2, indicating volume compensation between the nasal cavities. In conclusion, our study demonstrates that there is no significant difference in the normal range of AR measurements among Chinese, Malay and Indian ethnic groups. AR is able to determine the structural abnormality of the internal nasal cavity caused by septal deviation and inferior turbinate hypertrophy.

Failed medialization laryngoplasty: management by revision surgery

OBJECTIVE

The purpose of this study was to evaluate the cause of immediate and late medialization laryngoplasty failures and to describe their management.

METHODS

A retrospective analysis was performed in 20 patients who underwent revision surgery after failed medialization laryngoplasty. Analysis was based on preoperative spiral CT scan, preoperative and postoperative videostrobolaryngoscopy, and phonatory function measures.

RESULTS

Three major types of failures were identified. The most common problem was arytenoid rotation with a persistent posterior glottic gap (11 of 20). Malposition or wrong size of the implants resulted in a lateralized vocal fold or false vocal fold medialization (6 of 20). Three patients had implants that were extruding. Late atrophy and bowing resulted in a glottal gap (2 of 20). One patient had fibrosis around the implant requiring removal. Spiral CT scan of the larynx located the implant precisely and showed the degree of arytenoid rotation. Patients with arytenoid rotation and posterior gap had revision medialization combined with arytenoid adduction. Revision medialization was performed in 11 patients, arytenoid adduction in 12 patients, lipoinjection in 2 patients, and 4 implants were removed. The voice was improved in 15 patients. Improved voice was correlated with improved phonation time and reduced phonatory airflow rates.

CONCLUSION

Immediate and late failures of medialization laryngoplasty are due to several possible causes. Revision surgery is feasible and highly successful. To select between the surgical alternatives work up should include preoperative analysis of vocal function, videostrobolaryngoscopic analysis, and spiral CT of the larynx.

Arytenoid adduction combined with Gore-Tex medialization thyroplasty

OBJECTIVE

To describe the technique of combined Gore-Tex medialization thyroplasty with arytenoid adduction and to determine the long-term vocal outcome of patients treated for unilateral vocal cord paralysis with this procedure.

STUDY DESIGN

A retrospective chart review and patient reevaluation for patients treated at The University of Iowa Hospitals and Clinics between May 1995 and June 1999.

METHODS

The review addressed patient demographics, perioperative and long-term complications, and voice outcomes. Details of the surgical technique are provided within the manuscript.

RESULTS

Seventy-two Gore-Tex medialization procedures were completed. Arytenoid adduction was included in 22 of these procedures. This subset of patients was compared with the patients treated with Gore-Tex alone. No major postoperative complications occurred in either group. Preoperative and postoperative voice and videostroboscopy data were available for 19 arytenoid adduction patients and 25 Gore-Tex alone patients. On a seven-point scale (6 [severely abnormal] --> 0 [normal voice]), the average patient rating of voice dysfunction improved from 4.2 to 1.6 (arytenoid adduction) and 4.5 to 2.8 (Gore-Tex alone). Maximum phonation time improved from 6.9 seconds to 16.7 seconds in the arytenoid adduction group. Subjective voice assessment employing the four-point GRBAS scale (3 [severely abnormal] --> 0 [normal]) identified average improvement from an overall grade of 2.1 to 0.8 arytenoid adduction and 2.2 to 1.5 in the Gore-Tex alone group. Improvement was identified in the vocal quality of breathiness from 1.9 to 0.2 (arytenoid adduction) and 1.9 to 0.9 (Gore-Tex alone).

CONCLUSIONS

The combined technique of Gore-Tex medialization thyroplasty and arytenoid adduction provide functional results that appear to exceed the improvement attained with medialization alone.

Acoustic rhinometry: a study of transient and continuous noise techniques with nasal models

The objective of this study is to compare the properties of two of the most frequently used acoustic rhinometers: the EcoVision (Hood Laboratories, USA) using the transient technique, and the Rhin2100 (RhinoMetrics, Denmark) using the continuous wide-band technique. In the wide-band rhinometer (Rhin2100), the transient analog signals of traditional rhinometers (EcoVision), are replaced by a digitally produced continuous wide-band noise signal. Tubular models and a plastic model produced by stereolithography (SLA), representing the true replicate of the nasal anatomy, were used to compare the accuracy of the two rhinometers. The effect of increasing angling (0-50 degrees) between the sound wave tube and the cavity was evaluated in a tubular model. The curves obtained with the two rhinometers showed close similarity, and the acoustically derived volumes correlated well with the volumes of tubular (% error < 4%) as well as the complex nasal model (% error < 10.5%). Both rhinometers underestimated the minimum cross-sectional area (MCA) of the complex nasal model (mean % error complex model: Rhin2100 = -7.6%, EcoVision = -13%). The effect of increasing the angle between the nose adapter and the tubular models was small for both rhinometers (CV < 3% for MCA and CV < 1% for volumes). The similar, and in general, high accuracy of the two rhinometers evaluated, particularly in the complicated geometry of the SLA model, is an indication of the reliability of both. The small effect of changing the angle between the nose adapter and the models was unexpected and very encouraging. Nevertheless, some minor differences in performance and capabilities of the two rhinometers might influence interpretation and comparison of results. Further comparisons in a clinical setting are under current investigation.

Nasal nitric oxide is independent of nasal cavity volume

This study was performed to evaluate the relationship between nasal nitric oxide (NO) and changes in nasal cavity volume resulting from the topical application of xylometazoline and saline and between upright and supine posture. Nasal NO was measured using a fixed high flow technique that avoids contamination with lower airways NO. In nine healthy subjects nasal NO concentration was measured by a rapid response chemiluminescent analyzer. A tapered tube was inserted in one nostril, into which room air was insufflated to produce a constant flow of 100 mL/second; another tube was inserted into the opposite nostril for NO sampling (air exit side). Subjects were instructed to keep the vellum closed while NO was sampled through a sideport connected to the analyzer. Nasal cavity volume was measured by acoustic rhinometry from a segment of the acoustic pathway, 2 to 5 cm from the nostril. Nasal cavity volume and NO measurements were made at baseline, 15 minutes, and 60 minutes after intervention (administration of saline 0.9%, xylometazoline or posture changes on 3 consecutive days). Xylometazoline produced a significant increase in nasal cavity volume, together with a significant reduction in NO level at 15 and 60 minutes after intervention. In addition, the change from seated to supine position decreased the total nasal volume significantly, but without changes in nasal NO. No correlation was found between the magnitudes of changes in nasal NO and the changes in nasal volume. Topical application of xylomethazoline resulted in increased nasal cavity volume and reduced NO output. In contrast to previous published reports, a technique using high flow rate insufflation demonstrated an abscence of correlation between the magnitudes of changes in nasal NO and nasal cavity volume brought about by decongestant, saline, or posture.

Gastroesophageal reflux: A critical factor in pediatric subglottic stenosis

Gastroesophageal reflux (GER) plays a causative role in the development of subglottic stenosis (SGS) in children. This study examined the impact of aggressive antireflux therapy on the clinical outcomes of 35 children. Since 1994, 25 children were treated aggressively with omeprazole and cisapride before endoscopic surgical repair of their stenoses, which ranged from Cotton grades 1 to 3. Nine patients became asymptomatic on antireflux therapy alone. Endoscopic repair was performed in 16 patients. Endoscopic repair failed in only 1, who required tracheotomy. Before 1994, all children undergoing endoscopic repair of SGS were treated perioperatively for reflux. Endoscopic repair failed in 10 of the 57 children, and all required tracheotomy. The clinical outcome of these 10 patients after aggressive antireflux therapy is described. Five of the 10 have been decannulated. The role of double pH probe testing and the importance of the pharyngeal probe for monitoring the response to antireflux medication are described. The probe data suggest that in some instances GER may be limited to perioperative stress, but in many cases, especially in premature infants with SGS, GER can persist unabated for years and is not outgrown as the patient matures.