Microdissection or microspot CO2 laser for limited vocal fold benign lesions: a prospective randomized trial

Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts

PURPOSE OF REVIEW

Innovative otolaryngologists, speech language pathologists, and voice scientists have continued to advance our understanding of the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts. This article reviews the recent publications over the past 3 years with respect to these advances.

RECENT FINDINGS

Support for the notion that benign vocal fold lesions arise from phonatory trauma and vocal misuse continues to become evident. Changes in the molecular characteristics of the lamina propria in these lesions are beginning to be understood. For diagnostic purposes, the use of innovative technology such as ultrasonography and virtual laryngoscopy is being explored. Continued support for behavior modification as a primary treatment modality for benign vocal fold lesions has been published, and refinements in technical aspects of laryngeal microsurgery persist. Finally, outcomes studies have demonstrated improvements in vocal disability with both behavioral and surgical interventions.

SUMMARY

Clinical and basic research has furthered our understanding of benign vocal fold lesions and has expanded our diagnostic and therapeutic armamentarium for patients with dysphonia arising from these lesions.

Effects of steel scalpel, ultrasonic scalpel, CO2 laser, and monopolar and bipolar electrosurgery on wound healing in guinea pig oral mucosa

OBJECTIVE

The study's objective was to compare instrument performance and tissue healing when steel scalpel, ultrasonic scalpel, monopolar or bipolar electrosurgical instruments, or CO2 laser was used in an animal oral surgery model.

STUDY DESIGN

Prospective, blinded, randomized.

METHODS

Adult guinea pigs (N = 70) were randomly assigned to 5 groups (14 animals per group) for excision of 2-cm, full-thickness oral mucosa using steel scalpel, ultrasonic scalpel, monopolar or bipolar electrosurgical instruments, or CO2 laser. Postoperative pain was measured indirectly using weekly body weight changes. Animals from each group were killed on days 0, 7, 14, 21, and 28. Specimens were harvested for blinded histopathological study and tensile strength measurement. Instrument performance (hemostasis, tissue coagulation, tissue sticking) and wound healing (tissue re-epithelialization, degree of inflammation) were primary outcomes. Statistical analysis was performed using analysis of variance.

RESULTS

The ultrasonic scalpel was the best tool in controlling hemostasis, tissue coagulation, and tissue sticking. Significantly higher body weight gain ( P<.05) was noted at day 7 for monopolar and CO2 laser groups. Greatest tensile strength was seen in the steel scalpel and ultrasonic scalpel groups at the end of 28 days. Tissue re-epithelialization was fastest for the steel scalpel and ultrasonic scalpel groups (complete by day 7). Complete re-epithelialization of wounds of all treatment groups occurred by day 28. All groups had acute inflammation. Complete resolution of inflammation by day 14 took place in the steel scalpel and ultrasonic scalpel groups only.

CONCLUSION

Use of the ultrasonic scalpel produced faster re-epithelialization and greater tensile strength than laser or electrosurgical instruments, with results comparable to those seen with the steel scalpel.

Phonomicrosurgery in singers and performing artists: treatment outcomes, management theories, and future directions

Phonomicrosurgery in performing artists has historically been approached with great trepidation, and vocal outcome data are sparse. The vocal liability of surgically disturbing the superficial lamina propria (SLP) and epithelium must be balanced with the inherent detrimental vocal effect of the lesion(s). A prospective investigation was performed on 185 performing artists who underwent phonomicrosurgical resection of 365 lesions: 201 nodules, 71 polyps, 66 varices and ectasias, 13 cysts, 8 keratotic lesions, 2 granulomas, 2 Reinke's edema, and 2 papillomas. Nearly all patients with SLP lesions reported improvement in their postsurgical vocal function. This subjective result was supported by objective acoustic and aerodynamic measures. All postsurgical objective vocal function measures fell within normal limits, including a few that displayed presurgical abnormalities. However, given the relative insensitivity of standard objective measures to assess higher-level vocal performance-related factors, it is even more noteworthy that 8 of 24 objective measures displayed statistically significant postsurgical improvements in vocal function. Such changes in objective measures mostly reflect overall enhancement in the efficiency of voice production. Phonomicrosurgical resection of vocal fold lesions in performing artists is enjoying an expanding role because of a variety of improvements in diagnostic assessment, surgical instrumentation and techniques, and specialized rehabilitation. Most of these lesions are the result of phonotrauma and arise within the SLP. Successful management depends on prudent patient selection and counseling, ultraprecise technique, and vigorqus vocal rehabilitation. Furthermore, an understanding of the vocal function and dysfunction of this high-performance population provides all otolaryngologists who manage laryngeal problems with valuable information that they can extrapolate for use in their practices.

Surgical versus non-surgical interventions for vocal cord nodules

BACKGROUND

Vocal cord nodules are bilateral swellings of the mid-portion of the membranous vocal folds. They are of variable size and are characterised histologically by thickening of the epithelium with a variable degree of inflammatory action in the underlying superficial lamina propria. They characteristically produce hoarseness. Treatment of vocal cord nodules aims to eliminate or reduce this hoarseness.

OBJECTIVES

To assess the effectiveness of surgery versus non-surgical interventions for vocal cord nodules.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (CCTR) and Medline (1966-2000), Embase (1974-2000), Biological Abstracts (1970-2000), Biological Abstracts RRM (Reports, Reviews and Meetings) on CD-ROM (1989-2000) and review articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing any surgical intervention for vocal cord nodules with non-surgical treatment or no treatment.

DATA COLLECTION AND ANALYSIS

No suitable trials were identified.

MAIN RESULTS

No studies fulfilled the inclusion criteria.

REVIEWER'S CONCLUSIONS

There is a need for high quality randomised controlled trials to evaluate the effectiveness of surgical and non-surgical treatment of vocal cord nodules.