Hydroxyapatite versus titanium implant: Comparison of the functional outcome after vocal fold medialization in unilateral recurrent nerve paralysis

Pre- and intraoperative acoustic and functional assessment of the novel APrevent® VOIS implant during routine medialization thyroplasty

PURPOSE

Persistent unilateral vocal fold paralysis (UFVP) with glottal insufficiency often requires type I medialization thyroplasty (MT). Previous implants cannot be adjusted postoperatively if necessary. The newly developed APrevent^® VOIS implant (VOIS) can provide postoperative re-adjustment to avoid revision MT. The objective of this pilot study is to evaluate the VOIS intraoperatively concerning voice improvement, surgical feasibility and device handling.

METHODS

During routine MT, VOIS was applied short time in eight patients before the regular implantation of the Titanium Vocal Fold Medialization Implant (TVFMI™). In all patients, perceptual voice sound analysis using R(oughness)-B(reathiness)-H(oarseness)-scale, measurement of M(aximum)-P(honation)-T(ime) and glottal closure in videolaryngoscopy were performed before and after implanting VOIS/TVFMI™. Acoustic analyses of voice recordings were performed using freeware praat. Surgical feasibility, operative handling and device fitting of VOIS and TVFMI™ were assessed by the surgeon using V(isual)-A(nalog)-S(cale). Data were statistically analyzed with paired t test.

RESULT

All patients showed significant improvement of voice sound parameters after VOIS/TVFMI™ implantation. The mean RBH-scale improved from preoperative R = 2.1, B = 2.3, H = 2.5 to R = 0.6, B = 0.3, H = 0.8 after VOIS and R = 0.5, B = 0.3, H = 0.8 after TVFMI™ implantation. The mean MPT increased from preoperative 7.9 to 14.6 s after VOIS and 13.8 s after TVFMI™ implantation. VOIS/TVFMI™ achieved complete glottal closure in 7/8 patients. The satisfaction with intraoperative device fitting and device handling of VOIS was as good as that of TVFMI™.

CONCLUSION

The novel APrevent^® VOIS implant showed similar intraoperative voice improvement compared to routinely used TVFMI™ without adverse device events and with safe device fitting.

Stroboscopic assessment of unilateral vocal fold paralysis: a systematic review

PURPOSE

To review the relevant basic stroboscopic evaluations in unilateral vocal fold paralysis (UVFP). Our aim was twofold: (1) to determine the frequency of use of stroboscopic parameters in outcome evaluation after surgical treatment of UVFP using a Pareto diagram; and (2) to select the most relevant parameters in terms of a significant difference between pre- and post-surgical intervention for UVFP.

METHODS

A systematic review in PUBMED includes studies on stroboscopic evaluation in combination with UVFP and surgical treatment. The review was limited to English studies published between 1990 and March 2018. The most frequently used stroboscopic parameters were identified using a Pareto diagram. Then, 'the percentage of significance' for the most frequently stroboscopic parameters was identified by comparing the number of studies that showed a statistically significant change in pre- and post-treatment results with the total number of studies using the same parameters.

RESULTS

Seven stroboscopic parameters were nominated using the Pareto diagram. In decreasing order of citation frequency, periodicity, edge bowing, mucosal wave, glottic gap, position of vocal fold, amplitude, and symmetry have respective percentages of significance of 87.5%, 83.3%, 77.7%, 64.5%, 60%, 57.1%, and 50%. Five pertinent scales were selected for the most frequent and significant stroboscopic parameters.

CONCLUSIONS

The results indicate that periodicity, edge bowing, mucosal wave, glottic gap, and position of vocal fold represent the five most frequently used and relevant stroboscopic parameters in UVFP evaluation. The current review outlines a proposal scale of these stroboscopic parameters.

PROSPERO REGISTRATION NUMBER

CRD42019126786.

Parameters and Scales Used to Assess and Report Findings From Stroboscopy: A Systematic Review

OBJECTIVE

Laryngeal endoscopy with stroboscopy, a critical component of the assessment of voice disorders, is rarely used as a treatment outcome measure in the scientific literature. We hypothesized that this is because of the lack of a widely used standardized, validated, and reliable method to assess and report laryngeal anatomy and physiology, and undertook a systematic literature review to determine the extent of the inconsistencies of the parameters and scales used in voice treatment outcome studies.

STUDY DESIGN

Systematic literature review.

METHODS

We searched PubMed, Ovid, and Cochrane for studies where laryngeal endoscopy with stroboscopy was used as a treatment outcome measure with search terms representing "stroboscopy" and "treatment" guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards.

RESULTS

In the 62 included articles, we identified 141 terms representing 49 different parameters, which were further classified into 20 broad categories. The six most common parameters were magnitude of glottal gap, mucosal wave amplitude, location or shape of glottal gap, regularity of vibration, phase symmetry, and presence and size of specific lesions. Parameters were assessed on scales ranging from binary to 100 points. The number of scales used for each parameter varied from 1 to 24, with an average of four different scales per parameter.

CONCLUSIONS

There is a lack of agreement in the scientific literature regarding which parameters should be assessed to measure voice treatment outcomes and which terms and scales should be used for each parameter. This greatly diminishes comparison and clinical implementation of the results of treatment outcomes research in voice disorders. We highlight a previously published tool and recommend it for future use in research and clinical settings.

Computed tomographic assessment of the causal factors of unsuccessful medialization thyroplasty

CONCLUSION

The present results demonstrate that a small implant size, undercorrection of the vocal fold, antero-posterior implant malposition, and the use of expanded polytetrafluoroethylene (ePTFE) are the primary factors that cause a poor outcome of medialization thyroplasty (MT).

OBJECTIVES

To assess the postoperative laryngeal condition using computed tomography (CT) in patients with unilateral vocal fold paralysis who underwent MT alone, and to identify the primary causal factors in terms of the surgical procedures that affect the outcomes of MT.

METHODS

Twenty-two patients who underwent MT alone were divided into two groups based on either the maximal phonation time or the perceived vocal breathiness. Two laryngologists assessed the postoperative laryngeal CT images during sustained vowel phonation and judged whether there were abnormalities of the arytenoid cartilage position, window position, implant size, and implant position, as well as the degree of correction of the vocal fold. As implant material, a silicone block, ePTFE, and hydroxyapatite had been inserted in 2, 9, and 11 patients, respectively. Comparisons of the prevalence of abnormalities in the abovementioned factors between the different outcomes and between the types of material used for the implant were performed.

RESULTS

Twelve patients with a poor outcome and 10 with a good outcome showed 36 and 18 abnormal findings identified by either of the two laryngologists, respectively. In the poor outcome group, a smaller implant size and undercorrection of the vocal fold showed both high kappa values and a significantly higher prevalence than those in the good outcome group (p < 0.001 and p < 0.05), respectively. The comparison between material types demonstrated that the sheet-like material (ePTFE) group exhibited a significantly higher prevalence of undercorrection than the block-like material group (p < 0.05).

Comparison of the use of silastic with titanium prefabricated implant in type I thyroplasty✩✩Please cite this article as: Malik A, Ramalingam WVBS, Nilakantan A, Nair S, Ramesh AV, Raj P. Comparison of the use of silastic with titanium prefabricated implant in type I thyroplasty. Braz J Otorhinolaryngol. 2014;80:156-60

Introdução

A tireoplastia tipo I é o tratamento de escolha nas paralisias unilaterais das pregas vocais que não se recuperam espontaneamente.

Objetivos

Comparar o uso de implante de Silastic® com o uso de titânio pré-fabricado TVFMI® (Titanium Vocal Fold Medializing Implant) na tireoplastia tipo I para o tratamento da paralisia unilateral das pregas vocais com relação à melhora subjetiva e objetiva da voz, às alterações endoscópicas nas pregas vocais, ao tempo de cirurgia e à relação custo-benefício.

Método

Trata-se de um estudo prospectivo com 40 pacientes portadores de paralisia unilateral das pregas vocais submetidos à tireoplastia tipo I com implante de silastic® ou TVFMI®. A avaliação e comparação estatística foram realizadas antes e quatro semanas depois da cirurgia por meio de videolaringoscopia, estroboscopia, análise perceptiva (escala GRBAS-Grade, Roughness, Breathiness, Asthenia, Strain) e subjetiva (IDV-índice de desvantagem vocal) da voz e avaliação eletroglotográfica e avaliação acústica computadorizada. Também foram observados o tempo de cirurgia e o custo do implante.

Resultados

Embora os dois implantes mostrem melhora na qualidade da voz após a tireoplastia, o TVFMI® teve um resultado ligeiramente melhor na análise objetiva da voz. O TVFMI® levou menos tempo de cirurgia para ser inserido, porém foi mais caro.

Conclusão

O TVFMI® poderá ser preferencial na tireoplastia de medialização, já que possui melhores resultados vocais e leva menos tempo de cirurgia, porém é mais caro que o implante de Silastic®.

© 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

Long-term results after external vocal fold medialization thyroplasty with titanium vocal fold medialization implant (TVFMI)

Since its introduction in 1999 by Friedrich, the titanium vocal fold medialization implant (TVFMI) is widely used for medialization thyroplasty in glottal closure insufficiency. The purpose of this study was to investigate the long-term functional outcome after medialization thyroplasty using TVFMI. Between 1999 and 2009 123 patients (mean age 55.3 years, 76 male and 47 female) underwent medialization thyroplasty with the TVFMI (96 left, 27 right). For purpose of long-term follow-up, 33 patients could be examined. Prior to surgery, about 8 weeks and at least 1 year after surgery perceptual, acoustic, aerodynamic and videolaryngostroboscopic examinations have been performed. The interval between surgery and long-term follow-up was on average 57 (23-120) months. None of the 123 patients presented early major postoperative complications (e.g. implant dislocation, dyspnoea with need of tracheostomy, wound infection, postoperative bleeding). In three patients the TVFMI had to be removed 2-6 months after surgery due to granulation tissue formation. In one patient a subepithelial localization of the implant could be seen without necessity of removal. Perceptual and acoustic parameters were significantly improved after surgery with long-lasting effect even years after surgery. Airway resistance (R(aw)) showed an increase over time without a relevant negative impact on the peak expiratory flow (PEF). Medialization thyroplasty using TVFMI allows precise and save positioning of the implant with stable perceptual and acoustic improvement. The only postoperative complication was the development of endolaryngeal granulation tissue resulting in removal of the implant.