Therapeutic Efficacy of Basic Fibroblast Growth Factor in Patients With Vocal Fold Atrophy

Glottic insufficiency caused by vocal fold atrophy with or without sulcus: systematic review of outcome measurements

PURPOSE

Identifying outcome measurements instruments (OMIs) to evaluate treatment efficacy in patients with vocal fold atrophy and/or sulcus.

METHODS

Systematic review of records published before March 2021 by searching Pubmed and EMBASE. Included studies reported on adults (> 18 year) with dysphonia caused by glottic insufficiency due to vocal fold atrophy with or without sulcus, who were enrolled into a randomized controlled trial, a non-randomized controlled trial, a case-controlled study or a cohort study. All included studies described an intervention with at least one outcome measurement.

RESULTS

A total of 5456 studies were identified. After removing duplicates, screening title and abstract and full text screening of selected records, 34 publications were included in final analysis. From these 50 separate OMIs were recorded and categorized according to the ELS protocol by DeJonckere et al. (Eur Arch Otorhinolaryngol 258: 77-82, 2001). With most OMIs being used in multiple studies the total number of OMIs reported was 265. Nineteen (19) individual OMIs accounted for 80% of reports. The most frequently used OMIs according to category were: VHI and VHI-10 (subjective evaluation); G of GRBAS (perceptual evaluation); F0, Jitter and Shimmer (acoustic evaluation); MPT and MFR (aerodynamic evaluation) and glottic closure and mucosal wave (endoscopic evaluation). Of these OMIs VHI had a high percentage of significance of 90%.

CONCLUSION

This systematic review identifies the most used OMIs in patients with glottic incompetency due to vocal fold atrophy and/or sulcus as a step toward defining a Core Outcome Set (COS) for this population.

PROSPERO REGISTRATION

238274.

Voice Pitch Shaping and Genderization: New Needs of Cosmetic Phonoplastic Surgery

Voices can convey content, emotion, and essential information about an individual's gender and social information. Closely related to gender identification and sexual attraction, voices also positively affect many psychological factors of individuals. Surgeries have evolved from treating congenital diseases to fulfilling an individual's aesthetic needs for voice. Voice shaping is emerging as the next cosmetic surgery hotspot after skincare and appearance and body shaping. This paper summarizes the development of voice pitch shaping and genderization procedures out of the cosmetic need. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

Evaluating Interventions for Sulcus Vocalis or Vocal Fold Scar: A Systematic Review and Meta-analysis

BACKGROUND

Sulcus vocalis reflects varying degrees of vocal cord lamina propria (LP) damage. Many interventions have been discussed in the literature for addressing sulcus vocalis, but there is no universally accepted gold standard for its management.

AIM

We aim in our study to collectively evaluate the effectiveness of different relevant interventions in the literature used for sulcus vocalis or vocal fold scar.

METHODS

We searched five electronic databases to collect all relevant studies. Records were screened for eligibility. Data were extracted from the included studies independently. Our continuous outcomes were pooled in our single-arm meta-analysis as mean change (MC) and with 95% confidence interval (CI).

RESULTS

Our systematic review and meta-analysis included 43 studies encompassing 1302 patients. The jitter parameter indicated that laser degeneration and LP regeneration/scar degradation led to the highest improvements compared to their baseline, with pooled MC of -0.897 and -0.893, respectively. Graft interposition showed a MC of -0.848, while medialization and dissection had less pronounced changes at -0.200. Shimmer parameter results were similar, with medialization and laser degeneration leading to MC of -2.129 and -2.123, while LP regeneration/scar degradation and graft interposition showed smaller changes MC -1.530 and -1.217. For the noise-to-harmonic ratio (NHR) parameter, LP regeneration/scar degradation demonstrated MC = -0.028. In aerodynamics outcomes, graft interposition and LP regeneration/scar degradation showed the highest MCs in mean phonatory time (MPT) (4.214 and 3.467, respectively). Endoscopic outcomes for mucosal wave showed high improvements in medialization and graft interposition (MC = 10.40 and 10.18, respectively). Perceptual outcomes favored graft interposition in various parameters, while laser degeneration performed well in most categories. Graft interposition and LP regeneration/scar degradation had a high voice handicap index (VHI) (MC = -27.195 and -19.269, respectively).

CONCLUSION

Laser degeneration and LP regeneration/scar degradation were particularly effective in improving acoustic parameters. In aerodynamics, graft interposition and LP regeneration/scar degradation improved vocal efficiency compared to their baselines. Medialization and laser degeneration had the largest impact compared to their baseline on shimmer and MPT. Endoscopic assessments showed that medialization and graft interposition had high improvement in mucosal waves, and perceptual outcomes were generally high with graft interposition and laser degeneration.

Treatments for Age-related Vocal Atrophy: A Systematic Review

OBJECTIVE

Age-related vocal atrophy (ARVA) can dramatically affect voice, communication, and quality of life. The objectives of this systematic review were to (1) determine whether treatments for ARVA were superior to controls (2) compare the relative efficacy of procedural and behavioral treatments (3) review the various types of outcome measures, and (4) evaluate the quality of studies.

REVIEW METHODS

The literature was searched using strategies designed by a medical librarian (2/18/21, updated 3/9/22). Studies investigating treatments for bilateral vocal atrophy were included. Studies involving unilateral atrophy, presbyphonia (without endoscopic findings), or an absent comparator group were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist was used to guide this study.

RESULTS

After applying the inclusion/exclusion criteria, 8 articles remained, including 4 randomized trials and 4 cohort studies, and a narrative synthesis was performed. Surgical and behavioral treatments for ARVA appeared to be superior to control groups, based on specific outcome measures. However, the superiority of these treatments over controls was not uniformly observed across multiple outcome measures. When comparing different treatments, superiority could not be established based on the quality and completeness of the studies included in the systematic review. Outcome measures also varied between individual studies. Finally, the risk of bias was analyzed and scored. Consistent point deductions among reviewed studies were noted.

CONCLUSIONS

When comparing treatments for ARVA. Surgery and voice therapy were both superior to control groups based on specific outcome measures from different domains. Superiority of one treatment could not be established.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:2846-2855, 2023.

The use of basic fibroblast growth factor to improve vocal function: A systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis examines if intralaryngeal injection of basic fibroblast growth factor 2 (FGF2) can improve voice outcomes in those with vocal disability.

DESIGN

A Systematic review of original human studies reporting voice outcomes following intra-laryngeal injection of basic fibroblast growth factor 2 in those with vocal dysfunction. Databases searched were Medline (1946-July 2022), Embase (1947-July 2022), Cochrane database and Google Scholar.

SETTING

Secondary or tertiary care centres that undertook the management of voice pathology Hospital.

PARTICIPANTS

Inclusion criteria were original human studies reporting voice outcome measurements following intralaryngeal injection of FGF2 to treat vocal fold atrophy, vocal fold scarring, vocal fold sulcus or vocal fold palsy. Articles not written in English, studies that did not include human subjects and studies where voice outcome measures were not recorded before and after FGF2 injection were excluded from the review.

MAIN OUTCOME MEASURES

The primary outcome measure was maximum phonation time. Secondary outcome measures included acoustic analysis, glottic closure, mucosal wave formation, voice handicap index and GRBAS scale.

RESULTS

Fourteen articles were included out of a search of 1023 and one article was included from scanning reference lists. All studies had a single arm design without control groups. Conditions treated were vocal fold atrophy (n = 186), vocal cord paralysis (n = 74), vocal fold fibrosis (n = 74) and vocal fold sulcus (n = 56). A meta-analysis of six articles reporting on the use of FGF2 in patients with vocal fold atrophy showed a significant increase of mean maximum phonation time of 5.2 s (95% CI: 3.4-7.0) at 3-6 months following injection. A significant improvement in maximum phonation time, voice handicap index and glottic closure was found following injection in most studies assessed. No major adverse events were reported following injection.

CONCLUSIONS

To date, intralaryngeal injection of basic FGF2 appears to be safe and it may be able to improve voice outcomes in those with vocal dysfunction, especially vocal fold atrophy. Randomised controlled trials are needed to further evaluate efficacy and support the wider use of this therapy.

One Year Outcomes and Longitudinal Changes in Voice Improvement With Single High Dose Intracordal Trafermin Injections for Age-Related Vocal Fold Atrophy

OBJECTIVE

Although intracordal trafermin injection has been performed in the treatment of age-related vocal fold atrophy, the effects of single high dose trafermin injections are unknown. In this study, we examined the 1 year outcomes and longitudinal changes in voice improvement with single high dose intracordal trafermin injections.

STUDY DESIGN

Retrospective study with approval by our Ethics Committee.

METHODS

The medical records of 34 patients who underwent single high dose (50ug per side) intracordal trafermin injections under local anesthesia for vocal fold atrophy were retrospectively reviewed at 1 month pre-injection and 1 month, 6 months and 1 year post injection.

RESULTS

Maximum phonation time (MPT), pitch range (PR), Japanese version of voice handicap index (VHI), grade of GRBAS evaluation, and jitter% improved significantly at 1-year post-injection compared to 1-month pre-injection. MPT and PR improved as early as 1-month post-injection and continued to improve most at 1-year post-injection. VHI showed negative progression from 6-months to 1-year post-injection, during which time the speaking fundamental frequency (SFF) changed to the high pitch in men.

CONCLUSIONS

Single high dose intracordal trafermin injections can be expected to improve voice in the early post-injection period and to maintain its effect for 1 year. SFF may play a role in worsening VHI in men.

LEVEL OF EVIDENCE

level 4.

Evaluation of Safety After Intracordal Basic Fibroblast Growth Factor Injection

OBJECTIVES

Although there are many reports of voice improvement with intracordal trafermin (a basic fibroblast growth factor) injections under local anesthesia, few papers have documented the safety of trafermin. Therefore, we aimed to investigate whether trafermin is safer than control drugs (triamcinolone acetonide) early after intracordal injection under local anesthesia.

METHODS

We conducted a retrospective review from the medical records of patients who underwent intracordal injection with trafermin and triamcinolone acetonide under local anesthesia at our institution. Early postinjective complications were defined as changes in vital signs and chief complaints early after intracordal injection.

RESULTS

A total of 699 and 297 patients underwent intracordal injection under local anesthesia with trafermin and triamcinolone acetonide, respectively. Of these, 227 and 130 patients had early postinjective complications with trafermin and triamcinolone acetonide, retrospectively. The most common complications occurring with trafermin was increased blood pressure in 39 cases (5.58%): 17 cases (2.43%) of blood pressure increase of ≥20 mm Hg. Other complications included pharyngeal discomfort in 37 (5.29%), lightheadedness in 33 (4.72%), and phlegm discharge in 29 (4.15%). Triamcinolone acetonide caused pharyngeal discomfort in 28 patients (9.43%), phlegm discharge in 17 patients (5.72%), lightheadedness in 12 patients (4.04%), sore throat in 11 patients (3.70%), increased blood pressure in 10 patients (3.37%): 7 cases (2.36%) of blood pressure increase of ≥20 mm Hg, and dizziness in seven patients (2.36%). Statistical analysis of the complications between trafermin and triamcinolone acetonide showed no significant differences.

CONCLUSIONS

The proportion of early postinjective complications from intracordal injection of trafermin is no significant difference in that of triamcinolone acetonide. The results suggest that the early postinjective complications are not due to the drug action of trafermin, but rather to complications from the intracordal injection procedures. Intracordal trafermin injection may be safe in the short term.

Changes in serum basic fibroblast growth factor concentration following intracordal injection

Objective

Although many studies have reported improvements in voice outcomes with intracordal trafermin injection, there is a lack of data documenting its changes in serum basic fibroblast growth factor (bFGF) blood concentration. This study examined whether serum bFGF concentrations change after intracordal trafermin injection.

Methods

This retrospective study was conducted at Tokyo Voice Center. We investigated serum bFGF concentrations before and after injection in 40 patients who underwent intracordal trafermin injection. There were 26 males and 14 females, with an age ranging from 13 to 88 years (average 53.25 years). They were diagnosed with paralysis (15 patients), atrophy (15 patients), sulcus (8 patients), and others (2 patients: scar and functional), presenting with severe hoarseness that interfered with daily life.

Results

The mean pre- and post-injective serum bFGF concentration of the 40 patients was 6.689 and 4.658 pg/mL, respectively. The difference in mean serum bFGF concentration between pre- and post-injective was -2.031 pg/mL. The Pearson correlation coefficient was calculated to evaluate the correlation between dosage of trafermin and post-injective serum bFGF concentration, and a moderate correlation was found at r = 0.52. Generalized linear model regression analysis was performed for the purpose of adjusting for confounding among variables. The only variable that showed a statistically predominant association with post-injective serum bFGF concentrations was the dosage of trafermin, with an estimated regression coefficient of 0.048.

Conclusion

In this study, the dosage of trafermin we injected and post-injective serum bFGF concentrations were dose-dependent but the amount of changes in the serum bFGF concentration was negligible within the physiological range. Therefore, as with subcutaneous and wound administration, intracordal trafermin injections may be safe.

Level of Evidence

Level IV.

Age-dependent treatment effect of vocal fold steroid injection for benign vocal fold lesions

Objective

Benign vocal fold lesions (BVFLs) cause voice disorders and impair social life. Recently, office-based vocal fold steroid injection (VFSI) has gained attention as a minimally invasive treatment for BVFLs. This study aimed to analyze the age-dependent treatment effect of VFSI and to clarify the indications for treatment.

Methods

In this retrospective cohort study, a total of 83 patients with BVFLs were treated with a similar regimen of VFSI. Three or four months after the injection, age-dependent phonological functions were evaluated. The differences between pre- and post-treatment findings were analyzed using the Wilcoxon matched-pair signed-rank test, and the correlation between patient age and improvement rates were determined by Pearson's correlation coefficient.

Results

Improvement in voice handicap index (VHI), which was the primary endpoint, was observed. Subjective and objective voice quality measurements also showed significant improvements. Subgroup analyses revealed that there was no age-related difference in the improvement of voice quality and that there was no improvement in aerodynamic effect in patients over 45 years of age.

Conclusion

This study clarified the age-dependent treatment effect of VFSI and provided the important suggestion of establishing indication criteria for BVFLs. The study results provided clarity on the indication criteria of VFSI and served as an important indicator for tailoring treatment to patients' needs.

Level of Evidence

4.

The life-cycle and restoration of the human vocal fold

Objective

To better understand the challenges of designing therapies to treat damaged vocal fold lamina propria, it is essential to understand the biophysical and pathophysiological mechanisms involved in vocal fold development, maintenance, injury, and aging. This review critically analyses these points to try and direct future efforts and new strategies toward science-based solutions.

Data Sources & Review Methods

MEDLINE, Ovid Embase, and Wed of Science databases were used to identify relevant literature. A scoping review was performed following the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews checklist.

Results

The layered arrangement of the vocal fold, develops during early childhood and is maintained during adulthood unless injury occurs. The stellate cells of the macular flava are likely to be important in this process. The capacity for vocal fold regeneration and growth is lost during adulthood and repair results in the deposition of fibrous tissue from resident fibroblasts. With advancing age, viscoelastic tissue declines, possibly due to cell senescence. Strategies aimed at replacing fibrous tissue within the vocal folds must either stimulate resident cells or implant new cells to secrete healthy extracellular protein. Injection of basic fibroblast growth factor is the most widely reported therapy that aims to achieve this.

Conclusions

The pathways involved in vocal fold development, maintenance and aging are incompletely understood. Improved understanding has the potential to identify new treatment targets that could potentially overcome loss of vocal fold vibratory tissue.

Tissue Engineering as a Promising Treatment for Glottic Insufficiency: A Review on Biomolecules and Cell-Laden Hydrogel

Glottic insufficiency is widespread in the elderly population and occurs as a result of secondary damage or systemic disease. Tissue engineering is a viable treatment for glottic insufficiency since it aims to restore damaged nerve tissue and revitalize aging muscle. After injection into the biological system, injectable biomaterial delivers cost- and time-effectiveness while acting as a protective shield for cells and biomolecules. This article focuses on injectable biomaterials that transport cells and biomolecules in regenerated tissue, particularly adipose, muscle, and nerve tissue. We propose Wharton's Jelly mesenchymal stem cells (WJMSCs), induced pluripotent stem cells (IP-SCs), basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), hepatocyte growth factor (HGF), insulin growth factor-1 (IGF-1) and extracellular vesicle (EV) as potential cells and macromolecules to be included into biomaterials, with some particular testing to support them as a promising translational medicine for vocal fold regeneration.

Intracordal injection therapy for vocal fold scarring: Steroid versus basic fibroblast growth factor

Objectives

Vocal fold scarring is caused by replacement of vocal fold mucosa with fibrous tissue due to repeated inflammation or trauma. It can lead to severe dysphonia. It is currently treated conservatively and with phonosurgery and intracordal injections. Intracordal injection of steroid or basic fibroblast growth factor (bFGF) has been recently found to be useful for treating vocal fold scarring that does not respond to voice therapy.

Methods

This retrospective study involved the administration of steroid injection and bFGF injection bilaterally under local anesthesia in 16 patients each. Laboratory measurements of voice parameters were performed before and 3-6 months after injection.

Results

In the steroid injection group, the Voice Handicap Index (VHI) score significantly improved from 57.1 to 40.5, total Grade, Roughness, Breathiness, Asthenia, Strain (tGRBAS) score significantly improved from 4.2 to 2.6, and mean speech fundamental frequency (SFF) increased from 192.5 to 211.4 dB, but there was no improvement in maximum phonation time (MPT) and mean airflow rate (MFR). In the bFGF injection group, significant improvements in the VHI score (from 53.3 to 35.7), MPT (from 16.9 to 21.8 s) and MFR (from 314.6 to 210.5 ml/s) were seen; however, the tGRBAS score did not improve. In addition, the SFF significantly decreased from 178.1 to 160.5 Hz.

Conclusion

These results suggest that both steroid and bFGF injections are effective for treating vocal fold scarring, with steroids improving voice quality and bFGF improving glottic closure, thereby contributing to improvements in VHI scores.

Level of Evidence

4.

Analysis of the Correlation of Basic Fibroblast Growth Factor in Serum of Patients with Diffuse Large B-Cell Lymphoma with Clinicopathological Efficacy and International Prognostic Index

The correlation of basic fibroblast growth factor (bFGF) in serum of patients with diffuse large B-cell lymphoma (DLBCL) with clinicopathological efficacy and International Prognostic Index (IPI) is analyzed. 115 DLBCL patients admitted to our hospital for treatment from June 2020 to June 2021 are selected as the DLBCL patient group, 65 healthy subjects who received physical examination in our hospital during the same period are selected as the healthy control group, and the serum bFGF levels of DLBCL group and healthy control group are observed before treatment. The experimental results show that the serum bFGF expression of DLBCL patients is decreased significantly after chemotherapy, and the serum bFGF expression of DLBCL patients is closely related to the treatment effect, disease progression, tumor invasion, and prognosis, which has important clinical significance for judging the disease, treatment effect, and prognosis of patients.

Long-term results and safety of fibroblast growth factor injection for unilateral vocal fold paralysis

Objectives

Treatments for unilateral vocal fold paralysis (UVFP) include conservative voice rehabilitation, vocal fold injection, and laryngeal framework surgery. We proposed basic fibroblast growth factor (bFGF) injection as a potential novel treatment for UVFP and have reported the short-term results. In this study, we present the long-term results and safety of vocal fold bFGF injection as a treatment for UVFP.

Methods

This retrospective study included 42 patients (25 males and 17 females) with UVFP who were administered a local injection of bFGF. The injection regimen involved injecting FGF (0.5 μg/ml in 0.5 ml per side) into the bilateral vocal folds using a 23-gauge injection needle. Phonological outcomes were evaluated 6 months and 12 months after the injection.

Results

Overall, 26 patients received a single injection of bFGF, six patients received an additional injection, and 10 patients received the additional framework surgery. Maximum phonation time, mean flow rate, pitch range, jitter and shimmer percentages, the total GRBAS (grade, roughness, breathiness, asthenia, strain) score, and voice handicap index scores improved significantly in the long term. In patients who received the additional injection or framework surgery, the effects of bFGF injection were temporary, but did not interfere with the performance of the framework surgery.

Conclusion

In total, 42 patients who underwent vocal fold bFGF injections were reviewed. The bFGF injections were effective and safe in the long-term results for UVFP in the selected cases. Some patients with severe symptoms benefited from the additional framework surgery but not the additional bFGF injection.