Videostroboscopic assessment of unilateral vocal fold paralysis after augmentation with autologous fascia

Effects of Voice Therapy for Dysphonia due to Tension Imbalance in Unilateral Vocal Fold Paralysis and Paresis

OBJECTIVES

Medialization procedures, such as type I thyroplasty, arytenoid adduction, and vocal fold injection, are popular treatments for dysphonia due to unilateral vocal fold paralysis (UVFP). However, dysphonia occasionally persists after medialization procedures owing to tension imbalance. This tension imbalance causes diplophonia, asymmetry and aperiodic vibrational flutter in travelling wave motion. Currently, there is no established treatment for tension imbalance. We herein report two cases with residual dysphonia due to tension imbalance following medialization for chronic UVFP, and another case presenting with dysphonia due to tension imbalance following chronic unilateral vocal fold paresis.

METHODS

Three patients underwent voice therapy using flow phonation to facilitate increased airflow management in speech as well as forward oral resonance by focusing on balanced airflow. Phonatory outcomes were evaluated using stroboscopic findings, aerodynamic and acoustic measures, as well as self-rating.

RESULTS

Aerodynamic assessments, acoustic findings and self-ratings improved in all three cases after voice therapy. Stroboscopic findings prior to voice therapy showed asymmetric vibration with glottic gap, which was improved after voice therapy. Fundamental frequency (F0) also increased post-therapy.

CONCLUSIONS

In a previous canine study, it was shown that enhanced breath support with expiratory airflow resulted in increased F0, suggesting that enhanced breath support could increase vocal fold tension. The increased F0 achieved in the present cases following voice therapy may increase vocal fold tension with breath support. Thus, voice therapy using flow phonation may be effective for supporting vocal fold tension and improving dysphonia due to tension imbalance following UVFP and paresis.

Ten must know pseudolesions of the head and neck

Patients may present in the emergency setting for a variety of head and neck complaints such as fever, trouble swallowing, or a newly palpable mass. When reviewing radiologic head and neck exams for etiology of complaints, it is important to be familiar with the multiple pseudolesions that may mimic pathology. These may be normal variant anatomy, normal anatomy located in an atypical location, as well as iatrogenic or self-introduced foreign bodies. This review article discusses ten common pseudolesions encountered in the head and neck and their typical imaging appearance so that one does not mistake them for ominous pathology, thus preventing unnecessary follow-up, biopsy, or continued concern for the patient.

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.

Vocal fold augmentation with injectable polycaprolactone microspheres/pluronic F127 hydrogel: long-term in vivo study for the treatment of glottal insufficiency

There is increasing demand for reconstruction of glottal insufficiency. Several injection materials have been examined for this purpose, but all had limitations, such as poor long-term durability, migration from the injection site, inflammation, granuloma formation, and interference with vocal fold vibration due to viscoelastic mismatch. Here, we developed a novel injection material, consisting of polycaprolactone (PCL) microspheres, which exhibits better viscoelasticity than conventional materials, and Pluronic F127 carrier, which decreases the migration of the injection materials. The material was injected into rabbits with glottal insufficiency and compared with the FDA-approved injection material, calcium hydroxylapatite (CaHA). Endoscopic and histological examinations indicated that PCL/Pluronic F127 remained at the injection site with no inflammatory response or granuloma formation, whereas CaHA leaked out and migrated from the injection site. Therefore, vocal fold augmentation was almost completely retained during the 12-month follow-up period in this study. Moreover, induced phonation and high-speed recording of vocal fold vibration showed decreased vocal fold gap area in the PCL/Pluronic F127 group. Our newly developed injection material, PCL/Pluronic F127, permits efficient augmentation of paralyzed vocal fold without complications, a concept that can be applied clinically, as demonstrated by the successful long-term follow-up.

[Treatment of glottal gap]

Glottal gaps can be either physiological or pathological. The latter are multifactorial, predominantly organic in origin and occasionally functional. Organic causes include vocal fold paralysis or scarring, as well as a deficiency or excess of tissue. In addition to loss of the mucosal wave, the degree of hoarseness is primarily determined by the circumferential area of the glottal gap. It is thus important to quantify the extent of glottal insufficiency. Although a patient's symptoms form the basis for treatment decisions, these may be subjective and inadequately reflected by the results of auditory-perceptual evaluation, voice analysis and voice performance tests. The therapeutic approach should always combine phonosurgery with conventional voice therapy methods. Voice therapy utilises all the resources made available by the sphincter model of the aerodigestive tract and knowledge on the mechanism of voice production. The aim of phonosurgery is medialization, reconstruction or reinnervation by injection laryngoplasty or larynx framework surgery. These different methods can be combined and often applied directly after vocal fold surgery (primary reconstruction). In conclusion, the techniques described here can be effectively employed to compensate for glottal gaps.

Posterior glottic gap and age as factors predicting voice outcome of injection laryngoplasty in patients with unilateral vocal fold paralysis

Objectives:

This study aimed to analyse demographic profiles and pre-injection stroboscopic findings for patients with unilateral vocal fold paralysis, to investigate possible predictive factors for voice outcomes of injection laryngoplasty.

Materials and methods:

Fifty-nine unilateral vocal fold paralysis patients underwent vocal fold augmentation, using transcutaneous Artecoll (polymethyl methacrylate microspheres plus bovine collagen) injection into the paralysed vocal fold via the cricothyroid space. Three months later, patients were divided into improved (n = 44) and unimproved (n = 15) groups, using the perceptual grade-roughness-breathiness-asthenia-strain scale, and their clinical characteristics and pre-operative stroboscopic findings compared.

Results:

The improved group were significantly younger than the unimproved group (p = 0.000). The size of the posterior gap on phonation was closely associated with the outcome of injection laryngoplasty (p = 0.015).

Conclusion:

Younger patients with a smaller posterior glottic gap on phonation can be expected to have a more favourable outcome following injection laryngoplasty for correction of glottic insufficiency due to unilateral vocal fold paralysis.

Using laryngeal electromyography to differentiate presbylarynges from paresis

PURPOSE

Differential diagnosis of patients over 64 years of age reporting hoarseness is challenging. Laryngeal electromyography (LEMG) was used to determine the status of the recurrent and superior laryngeal nerves. The authors hypothesized that individuals with hoarseness but normal LEMG would have measures similar to those of patients from previous studies with presbylarynges and significantly different from those of patients with abnormal LEMG.

METHOD

A retrospective chart review of acoustic, aerodynamic, endoscopic, and self-rating measures was completed for 52 individuals over 64 years of age reporting moderate to severe hoarseness.

RESULTS

Individuals with normal LEMG had measures similar to those of patients from previous studies diagnosed with presbylarynges. The group with LEMG abnormalities was subcategorized by specific nerve(s) affected. Significant differences were found for measures between presbylarynges and unilateral but not bilateral paresis groups. Several endoscopic findings were observed more often than expected in the presbylarynges group. Using electromyography as a gold standard, the presence of any impairment in arytenoid movement had the most sensitivity (77%) in making the diagnosis of paresis, and the absence of any impairment had the most specificity (67%) in making the diagnosis of presbylarynges.

CONCLUSION

LEMG may be useful in differentially diagnosing hoarseness in older patients, especially to distinguish between bilateral paresis and presbylarynges.

Advances in laryngeal imaging

Imaging and image analysis became an important issue in laryngeal diagnostics. Various techniques, such as videostroboscopy, videokymography, digital kymography, or ultrasonography are available and are used in research and clinical practice. This paper reviews recent advances in imaging for laryngeal diagnostics.

Mucosal Wave: A Normophonic Study Across Visualization Techniques

Visualization of vocal fold vibration is essential for accurate diagnoses and optimal treatment of persons with voice disorders. Recently, scientific and anecdotal reports have evidenced an increased amount of variation in the diagnostically relevant features of extent and symmetry of mucosal wave magnitude in normophonic speakers. The objectives of this study were to preliminarily ascertain the variation in mucosal wave magnitude and symmetry for normophonic speakers as assessed via standard and novel techniques, and compare findings across modal and pressed phonations. A correlational design with a multiple baseline across visualization methods approach was used. Mucosal wave presence, magnitude, and symmetry from 52 normophonic speakers were judged via stroboscopy, high-speed videoendoscopy (HSV) playback, mucosal wave playback, and mucosal wave kymography playback. Results demonstrate a prevalence of atypical magnitude and symmetry of mucosal wave during modal and pressed phonations by normophonic persons, differences across techniques, and a relationship between judgments and habitual fundamental frequency. Given the prevalence of mucosal wave magnitude and symmetry variations in the normophonic population, overdiagnosis may be possible without caution. The various visualization techniques provided unique information suggesting that it may be beneficial to use both full view and kymographic visualization techniques in combination. A major restriction of the current commercial HSV systems is the frame rate, typically limited to 2000 frames per second, which appears insufficient for most female habitual phonations.

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.

Treatment of vocal fold immobility by injectable homologous collagen: short-term results

Various implant materials have been used to treat glottic insufficiency by means of intracordal injection. So far, autologous fat is the most commonly used. Homologous collagen is a new injectable acellular graft material. This collagen, made of 200-mu particles, is delivered as a freeze-dried powder in a 1-cc-unit syringe and is rehydrated with standard saline solution prior to injection. A prospective study was conducted on 23 patients with unilateral vocal fold paralysis. All injections were performed under general anesthesia using the collagen injection system and a 25-gauge needle. A mean quantity of 1.05 ml (SD: 0.41) of collagen was injected as much as possible in the deep part of the lamina propria. Voicing was resumed after 2 days. The mean follow-up was of 8 months (range: 2-18). Functional results were measured according to the ELS protocol. G(rade), R(oughness) and B(reathiness) according to Hirano were reported on a four-point grading scale showing an improvement from 2.13 to 1.13 for G (P<0.001), from 1.50 to 0.82 for R (P<0.002) and from 1.73 to 1.05 for B (P<0.001). The parameters selected for videolaryngostroboscopy, G(lottal) (Clo)sure, (R)egularity, (M)ucosal (W)ave and (Sym)metry, were measured on a visual analog scale. They showed an improvement from 23 to 19 for Clo (P=0.087), from 15 to 6 for R (P=0.001), from 15 to 11 for MW (P=0.039) and from 17 to 8 for Sym (P=0.001). For the aerodynamic parameters, the maximum phonation time (MPT) and the phonation quotient (PQ) showed an improvement from 5.8 to 8.9 s (P=0.002) and from 704.5 to 449.7 ml/s (P=0.004), respectively. The acoustic parameters were improved from 5.3 to 3.6 (P=0.045) for the jitter (%), they didn't change for the shimmer [(%): 2.4], and they were improved non-significantly from 187.9 to 218.7 Hg for the frequency range. The lowest level intensity was non-significantly increased from 49.6 to 51.3 dB. Regarding the subjective evaluation, the Voice Handicap Index (VHI) was improved from 65 to 37. To date, no homologous collagen-related morbidity has been observed. Injectable homologous collagen appears to be safe and suitable for injection laryngoplasty. Long-term results are pending.

Injection laryngoplasty for management of unilateral vocal fold paralysis

PURPOSE OF REVIEW

The purpose of this review is to provide an up-to-date review of injection laryngoplasty technique and currently available injectable materials in the management of unilateral vocal fold paralysis (UVP).

RECENT FINDINGS

Many new materials are currently available as substances for injection laryngoplasty. These materials have been developed along distinct of lines reasoning that address the inherent shortcomings of the previously available injectable substances, namely, poor tissue biocompatibility and poor persistence within the larynx. Accordingly, the past decade has seen heightened efforts toward developing implants with improved biocompatibility and longevity. The past year has witnessed publications reporting animal studies and, on occasion, human clinical trials involving the intralaryngeal injection of calcium hydroxyl-appetite, autologous fascia, particulate silicone and hyaluronic acid derivatives, and others, for managing glottic insufficiency.

SUMMARY

In recent years, the application of injection laryngoplasty to unilateral vocal fold paralysis (UVP) has regained popularity. The technique of injection laryngoplasty has several appealing qualities including relative technical ease, low cost, and wide availability in many clinical settings. A growing number of injectable substances have been developed and tested in the clinical setting of glottic insufficiency. When used to manage unilateral vocal fold paralysis, however, injection laryngoplasty has one irrefutable shortcoming: an inability to address posterior glottic insufficiency. Therefore, while injection laryngoplasty technique becomes increasingly popular for vocal fold augmentation in cases vocal fold paresis, atrophy, and scarring, its role in the treatment of UVP should be limited to cases with an appropriate glottal defect. These techniques should be considered as part of a complimentary armamentarium with framework surgery.