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

Photoangiolytic Laser Treatment of Early Glottic Cancer: A New Management Strategy

The 532 nm pulsed KTP (potassium titanyl phosphate) laser and the 585 nm pulsed dye laser (PDL) are photoangiolytic lasers that have been demonstrated to be effective for managing vocal fold dysplasia. The putative mechanism of action is selective photoangiolysis of the sublesional microcirculation. On the basis of this experience, early glottic cancers were treated by selectively targeting the intralesional and sublesional microvasculature. This approach was derived from Folkman's concepts of neoplastic growth resulting from tumor angiogenesis. Staged microlaryngeal treatment was adopted, because it facilitated optimal functional results, and was considered safe, because early glottic cancer rarely metastasizes. Furthermore, intercurrent disease during conventional incremental radiotherapy is typical in treating early glottic cancer. A pilot group of 22 patients with early glottic cancer (13 T1, 9 T2) were treated with a fiber-based angiolytic laser. Eleven of the 22 had unilateral disease and were entirely treated by laser photoangiolysis as a sole modality. Eleven of the 22 had bilateral disease; 5 of the 11 were treated entirely (bilaterally) by laser photoangiolysis, and 6 of the 11 only underwent laser treatment of the less involved vocal fold, with conventional resection being done on the dominant side of the cancer. The initial 8 of the 22 were treated with the PDL, and the latter 14 of the 22 were treated with the pulsed KTP laser. No patient has cancer presently, and none have undergone posttreatment radiotherapy or open surgery. The mean follow-up is 27 months, 13 of the 22 patients have at least 2 years of follow-up, and the first patient was treated just over 5 years ago. Objective measures of vocal function revealed that photoangiolytic treatment of early glottic cancer resulted in significant postoperative improvements despite the fact that half of the patients had bilateral disease. Angiolytic lasers effectively involuted early glottic cancer, with microsurgically directed nonionizing radiation of the dense neoplastic blood supply resulting in complete tumor regression. This approach is conceptually attractive, because it is repeatable, it preserves all conventional cancer treatment options, and it results in excellent vocal function by improving phonatory mucosal wave vibration. Observations from this investigation suggest that this new and novel cancer treatment strategy is effective; however, larger patient cohorts, longer follow-up, and multi-institutional confirmation will be necessary to establish incontrovertible oncological efficacy.

Injection Versus Medialization Laryngoplasty for the Treatment of Unilateral Vocal Fold Paralysis

OBJECTIVE/HYPOTHESIS

To determine whether injection laryngoplasty or medialization laryngoplasty is more effective in the treatment of unilateral vocal fold paralysis.

STUDY DESIGN

A retrospective study of patients with unilateral vocal fold paralysis who underwent either injection or medialization laryngoplasty at the University of Arkansas for Medical Sciences between July 29, 2003 and March 8, 2005.

METHODS

The data analyzed included patient characteristics and type of intervention, along with the pretreatment and posttreatment voice parameters of videostrobolaryngoscopy, perceptual analysis, and patients' subjective voice assessment.

RESULTS

Nineteen patients were evaluated. The average time from intervention to posttreatment evaluation was 3 (range, 1-9) months. Improvements were demonstrated in all three voice parameters in both the injection and the medialization groups. No significant differences were found in the degree of improvement between the two groups. Videostrobolaryngoscopy and the perceptual analysis, both rated by the authors, correlated well with each other, but they both correlated poorly with the patients' subjective voice analysis.

CONCLUSIONS

Injection and medialization laryngoplasty were comparable in their improvement of subjective and objective voice outcomes. Both treatment modalities should be included in the otolaryngologist's armamentarium for managing unilateral vocal fold paralysis.

Phonosurgery after endoscopic cordectomies. II. Delayed medialization techniques for major glottic incompetence after total and extended resections

Major glottic incompetence is often encountered after total (Type IV) and extended (Type V) cordectomies and is responsible for poor vocal outcome. Even though the vast majority of patients do not complain of significant limitations in daily life, a selected number of them eventually require some sort of phonosurgical treatment in order to improve voice quality. Different techniques have been described in the literature to ameliorate long-term vocal outcome. The aim of the present report was to retrospectively describe our experience in this challenging clinical scenario. Between April 1999 and March 2005, 24 patients previously treated by Type IV-V endoscopic cordectomies for T1 and T2 glottic cancer presented unsatisfactory vocal outcome in spite of intensive speech therapy and therefore underwent some form of phonosurgical treatment at our Department after at least 12 months without evidence of local-regional recurrence. Patients were treated by medialization thyroplasty with a Montgomery System Implant (two cases), Gore-Tex strips (16 cases), medialization thyroplasty with Gore-Tex associated with anterior commissure laryngoplasty (three cases), and augmentation with Vox Implant injection (three cases). Nineteen patients had comprehensive evaluation by videolaryngoscopic examination and subjective, perceptual, and objective voice analysis both in the pre-phonosurgical treatment period and after at least 12 months. Comparison of pre- and postoperative videolaryngoscopic findings revealed improved glottic closure in 74% of patients. Comparison between the pre- and postoperative subjective, perceptual, and objective voice analysis by the Wilcoxon matched-pair test showed a statistically significant improvement from a Voice Handicap Index mean value of 46 (preoperative) to 21 (postoperative); an improvement for each parameter of the GRBAS scale with statistically significant differences for G, B, A, and S, while R showed only an improving trend; and statistically significant improvement in the mean values of Jitter, Shimmer, Noise to Harmonic Ratio, and Maximum Phonation Time. In conclusion, the different delayed phonosurgical procedures herein used demonstrate the possibility to improve vocal outcomes after total and extended cordectomies in selected and highly motivated patients that have not achieved satisfactory performance after prolonged and intensive speech therapy.

Histopathologic study of minced and injected expanded polytetrafluoroethylene (Gore-Tex) in quadriceps muscle of rats for injection laryngoplasty

OBJECTIVE

Gore-Tex has not yet been used as an injection material, and no animal study has been performed. The purpose of this study was to investigate the histopathological and volumetric changes of minced and injected expanded polytetrafluoroethylene (Gore-Tex) in the quadriceps muscle of rats to find out its possibility as an injection material in future injection laryngoplasty.

DESIGN

A prospective study was performed in 13 Wistar rats.

METHODS

The 50+/-5 mg Gore-Tex vascular graft was minced until it was fine enough to pass through a 16G injection cannula. To create viscosity in order to avoid precipitation, minced Gore-Tex was mixed with sodium hyaluronate (SH) gel. 0.5 ml of this mixture was injected into the middle part of the right quadriceps muscle of each subject. Then, pure SH (0.5 ml) was injected into the middle part of the left quadriceps muscle of each subject. To compare the volumetric and histopathological changes of the injection area occupied by the materials over the time, two rats were sacrificed 1 day after the procedure, four rats after 1 month, four rats after 3 months and three rats after 6 months.

RESULTS

In pure SH: SH was observed as an effusion in the muscle of one subject on the first day only. We did not detect SH in the muscle in the first, third and sixth months and, as a result, there was no augmentation. Inflammation and fibrosis was not detected in any of these applications of SH. In minced Gore-Tex+SH gel mixture: SH was again eliminated from the muscle in a very short period of time, but the remaining Gore-Tex created a 15.8% volumetric gain. Fibrosis and capsule formation began in the first month and, in the sixth month; we observed connective tissue surrounding the Gore-Tex material. Ingrowth of connective tissue into the Gore-Tex, though not present in the first month, occurred partially in the third and significantly in the sixth month. In addition, we observed foreign body granuloma formation after the third month.

CONCLUSIONS

Pure SH, though easily applicable, was immediately eliminated leaving no trace. In the relatively difficult applications of Gore-Tex mixed with SH, however, there was residual Gore-Tex present in all subjects throughout the study. Gore-Tex may be an applicable material for injection laryngoplasty.

Sulcus vocalis: a review

Sulcus vocalis is described as a groove at the free edge of the vocal fold. Different types have been described: sulcus type I is superficial and may be considered as moreless physiologic. Sulcus type IIa corresponds to a kind of vergeture along the margin of the vocal fold. Its deepness is variable but sulcus vergeture may involve deeper layers of the lamina propria. Sulcus type IIb or pounch may be considered as an open cyst. Sulcus lead to a complex glottic dysfunction with, in the same time, a glottal leakage responsible for the breathy component of the dysphonia and a stiffness of the free edge responsible for the roughness. Diagnosis may be difficult even with the help of stroboscopy and finally is sometimes done only under general anesthesia. Etiology remains controversial and the authors present arguments for each theory, acquired or congenital. Treatment options include phonosurgery and speech therapy but phonosurgery gives results often disappointing and surgical treatment must be indicated prudently and patient must be intensively informed on what he or she can expect from the treatment that is mainly an increase of the loudness of the voice.

Recurrent Laryngeal Nerve Injuries After Esophagectomy

Unilateral vocal-cord paralysis after esophagectomy involving a cervical anastomosis is uncommon in experienced hands but can cause marked morbidity because of pulmonary complications. It is important for the surgeon to understand the anatomy of the recurrent laryngeal nerve to avoid this complication. The diagnosis is usually easily made at the bedside and can be confirmed by visualization of the glottis. Early treatment may include supportive care with a speech pathologist or injection of the vocal-cord with temporary material to improve glottic closure. Definitive treatment can best be performed by medialization thyroplasty.

[Therapy for unilateral vocal fold palsy]

The main symptom of unilateral vocal fold palsy is hoarseness, which can cause considerable disturbance to the patient depending on its extent and the patient's individual situation. Therapy aims at the restitution of a tuneful and resilient voice, which can be achieved by surgical or conservative means, improving the glottal closure and synchronizing the vocal fold vibrations during phonation. Vocal therapy is a common conservative method that may be supported by psychotherapeutic or physical procedures. In surgical therapy, there is a distinction between techniques of endoscopic augmentation by injecting different materials into the vocal folds and transcutaneous laryngeal framework surgery, i.e., transferring the paralyzed vocal fold to the glottal midline. Particularly apt for injection are biocompatible materials amount and position whose can easily be controlled. However, the inevitable resorption of many materials causes deterioration in voice quality. Furthermore, the change of vocal fold morphology obstructs regular phonatory vibration. On the other hand, medialization thyroplasty leads to permanent voice amelioration without a substantial complication rate when performed by experienced surgeons.

Vocal fold augmentation with injectable calcium hydroxylapatite: short-term results

Symptoms of unilateral vocal fold paralysis are improved significantly by augmenting the paralyzed vocal fold via vocal fold injection. In this trial, augmentation with a new calcium hydroxylapatite implant was evaluated. In addition, two different phonosurgical injection techniques were used, and these procedures were compared for accuracy and reliability. A total of 11 terminal patients with unilateral vocal fold paralysis underwent vocal fold injection with calcium hydroxylapatite. Efficacy of the implant was evaluated by comparing results from the Voice Handicap Index (VHI) and mean airflow measurements before and 6 months after injection. Surgeon evaluations determined the comparative benefits of either endoscopic direct vocal fold injection or percutaneous vocal fold injection. Six-month data were obtained for a cohort of five patients. VHI scores improved for all five patients available for full evaluation and four of the five achieved improvements in mean airflow rates. Of the remaining patients, one later had a medialization laryngoplasty, two died from their terminal diseases before the 6-month follow-up, and two of the remaining three reported satisfaction with the results via telephone follow-up. Vocal fold injection via endoscopic, direct laryngoscopy was found to be a more reliable procedure for vocal fold injection than percutaneous injection. Slight overinjection (10% to 15%) was found to provide optimum results. Vocal fold injection of calcium hydroxylapatite for unilateral vocal fold paralysis improved voice quality and reduced mean airflow rates in this patient group with short-term results. Long-term studies are needed to confirm the durability of these findings.

Optimizing voice after endoscopic partial laryngectomy

Phonosurgical management of early and midsized glottic cancer has evolved considerably during the past decade. There has been a partial migration from transcervical to transoral partial laryngectomy to diminish perioperative morbidity (ie, tracheotomy) and to facilitate subsequent voice restoration. After an endoscopic partial laryngectomy heals, a medialization of the glottal neocord should be done. An endolaryngeal injection or transcervical medialization is used to reconstruct the glottal valve and the associated aerodynamic competency, which ultimately enhance voice quality. These reconstructive techniques will improve the voice outcome subsequent to almost any endoscopic vertical partial laryngectomy; however,a near-normal conversational level voice can be achieved inpatients in whom there is one remaining normal vocal fold. These favorable results are based on the fact that after effective glottal closure is achieved through the reconstruction, the primary oscillator is the layered microstructure of noncancerous glottal tissue.

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.

Evidence-based treatment of paralytic dysphonia: making sense of outcomes and efficacy data

The criteria used to determine the success or failure of a given treatment for vocal fold paralysis are fundamental components of routine clinical practice and treatment outcomes research for the surgeon and voice therapist. The purpose of this article is to offer a guide to the critical interpretation of available measures of out-come and efficacy for this patient population. Such data form the basis for the practice of evidence-based medicine and voice therapy,essential if the standard of care is to evolve to the benefit of the patient. A better understanding of the potentials and limitations of each measure is important for treatment planning and patient counseling and, ultimately, for the conception of future well-designed clinical research. The complex issues regarding outcomes measurement are addressed here within the context of current treatment literature on vocal fold paralysis. Particular emphasis is placed on realistic data gathering within clinical practice.