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

Safety and Adverse Events of Medialization Thyroplasty: A Systematic Review

INTRODUCTION

Unilateral vocal fold paralysis or paresis (UVFP) is a condition that causes significant morbidity due to dysphonia, dysphagia, and aspiration. Type I medialization thyroplasty (MT) is the current mainstay surgical treatment for UVFP. Though widely considered a safe procedure, concerns exist over possible airway complications which can lead to overnight observation. Herein, we report a systematic review of the safety and adverse events of MT to aid in determining the safety of same-day discharge.

DATA SOURCES

PubMed and Embase databases.

REVIEW METHODS

Our search identified studies investigating complications associated with MT. Articles were selected if published between January 1, 1989 and March 15, 2023. Abstracts were screened, and data were extracted from included studies. Only Type I MT procedures were included; case reports were excluded. Participant characteristics, intervention details, results, and adverse events were extracted.

RESULTS

The database query identified 751 abstracts, of which 46 studies met eligibility criteria. A total of 2426 patients underwent MT. The most common implant was Silastic (n = 898, 37.0%) followed by Gore-Tex (n = 664, 27.4%). There were 254 (10.5%) total complications reported; 110 (4.5%) were considered major. The most common complication was nonobstructive hematoma (n = 59, 2.4%) followed by hemorrhage (n = 36, 1.5%). Implant extrusion (n = 24, 0.99%) or displacement (n = 15, 0.62%) occurred mostly in Silastic and Gore-Tex implants. Same-day discharge occurred with 429 patients and was not associated with adverse events.

CONCLUSIONS

UVFP can be reliably improved by MT with a low risk of complications. Outpatient MT is a promising treatment with a favorable safety profile. Laryngoscope, 134:1994-2004, 2024.

Long-term voice evaluation after arytenoid adduction surgery in patients with unilateral vocal fold paralysis

PURPOSE

Laryngeal framework surgery, including medialization laryngoplasty and arytenoid adduction (AA), is expected to have a lasting or permanent effect in patients with unilateral vocal fold paralysis (UVFP); however, there are few reports about the long-term outcomes of AA. This study aimed to evaluate the long-term postoperative effects of AA surgery and examine its stability and reliability.

METHODS

This study collected the voice handicap index (VHI) questionnaire from patients with UVFP who underwent AA more than 2 years previously. The VHI values preoperatively and 3 months postoperatively (early postoperative evaluation) were retrospectively calculated, and VHI values more than 2 years after surgery (late postoperative evaluation) were collected by mailing a sheet to the patients and asking to fill and return it. Possible influenced subscales such as age, sex, causes of UVFP, affected side, and surgeons were also analyzed.

RESULTS

A total of 77 patients with UVFP who underwent AA had significantly lower early and late postoperative evaluations than preoperative evaluations. In 38 patients with no missing values, there were no significant differences between early and late postoperative evaluations, measured at a median of approximately 5 years. There were also no significant differences between early and late postoperative evaluations in any of the subscale groups.

CONCLUSION

Patients with UVFP who underwent AA surgery achieved stable voice improvement in the long term after surgery.

Active and Passive Bioimplants for Vocal Fold Paralysis

Vocal fold paralysis is one of the diseases that particularly affect quality of life. While unilateral paralysis leads to glottis closure insufficiency and hoarseness, bilateral paralysis compromises respiration and limits the exercise tolerance. Bioimplants have been used to treat persistent paralysis for over 100 years. The spectrum ranges from autologous tissue transfer and resorbable or permanent injection materials to composite thyroplasty implants and active electrical implants for neurostimulation of the larynx. If bioimplants are used in accordance with the recommendations, the quality of life of affected patients can be significantly improved today.

Keys to successful type-1 thyroplasty with Montgomery® implant for unilateral laryngeal immobility in adults

Based on a review of the medical literature, the authors document the key technical points and pitfalls in type I thyroplasty with Montgomery® implant, and the main results and indications in unilateral laryngeal immobility.

Long-term treatment outcome of type 1 thyroplasty using novel titanium medialization laryngoplasty implant combined with arytenoid adduction for unilateral vocal cord paralysis: single-arm interventional study at a single institution

OBJECTIVE

To evaluate the long-term treatment outcome of type 1 thyroplasty with novel rearrangeable titanium medialization laryngoplasty implant (TMLI) combined with arytenoid adduction (AA) for unilateral vocal cord paralysis (UVFP) in the authors' institution.

METHODS

A total of 16 Japanese patients with UVFP who received type 1 thyroplasty using TMLI with arytenoid adduction was enrolled in this single-arm, non-randomized interventional study. The results of the auditory perceptual assessment, aerodynamic examination, acoustic measurement, and patient-based survey on these patients were evaluated preoperatively and at 3, 6, and 12 months postoperatively.

RESULTS

Type 1 thyroplasty using TMLI with arytenoid adduction for our patient series presented significant improvements in maximum phonation time, mean flow rates, GRBAS scale, the Voice Handicap Index and the Voice-Related Quality of Life score over the 12-month postoperative period.

CONCLUSION

Type 1 thyroplasty using TMLI with arytenoid adduction was quite effective for obtaining satisfactory postoperative voice improvement without any surgical complication over the long-term period.

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.

Impact of Subharmonic and Aperiodic Laryngeal Dynamics on the Phonatory Process Analyzed in Ex Vivo Rabbit Models

Normal voice is characterized by periodic oscillations of the vocal folds. On the other hand, disordered voice dynamics (e.g., subharmonic and aperiodic oscillations) are often associated with voice pathologies and dysphonia. Unfortunately, not all investigations may be conducted on human subjects; hence animal laryngeal studies have been performed for many years to better understand human phonation. The rabbit larynx has been shown to be a potential model of the human larynx. Despite this fact, only a few studies regarding the phonatory parameters of rabbit larynges have been performed. Further, to the best of our knowledge, no ex vivo study has systematically investigated phonatory parameters from high-speed, audio and subglottal pressure data with irregular oscillations. To remedy this, the present study analyzes experiments with sustained phonation in 11 ex vivo rabbit larynges for 51 conditions of disordered vocal fold dynamics. (1) The results of this study support previous findings on non-disordered data, that the stronger the glottal closure insufficiency is during phonation, the worse the phonatory characteristics are; (2) aperiodic oscillations showed worse phonatory results than subharmonic oscillations; (3) in the presence of both types of irregular vibrations, the voice quality (i.e., cepstral peak prominence) of the audio and subglottal signal greatly deteriorated compared to normal/periodic vibrations. In summary, our results suggest that the presence of both types of irregular vibration have a major impact on voice quality and should be considered along with glottal closure measures in medical diagnosis and treatment.

Investigation of phonatory characteristics using ex vivo rabbit larynges

Quantitative analysis of phonatory characteristics of rabbits has been widely neglected. However, preliminary studies established the rabbit larynx as a potential model of human phonation. This study reports quantitative data on phonation using ex vivo rabbit larynx models to achieve more insight into dependencies of three main components of the phonation process, including airflow, vocal fold dynamics, and the acoustic output. Sustained phonation was induced in 11 ex vivo rabbit larynges. For 414 phonatory conditions, vocal fold vibrations, acoustic, and aerodynamic parameters were analyzed as functions of longitudinal vocal fold pre-stress, applied air flow, and glottal closure insufficiency. Dimensions of the vocal folds were measured and histological data were analyzed. Glottal closure characteristics improved for increasing longitudinal pre-stress and applied airflow. For the subglottal pressure signal only the cepstral peak prominence showed dependency on glottal closure. In contrast, vibrational, acoustic, and aerodynamic parameters were found to be highly dependent on the degree of glottal closure: The more complete the glottal closure during phonation, the better the aerodynamic and acoustic characteristics. Hence, complete or at least partial glottal closure appears to enhance acoustic signal quality. Finally, results validate the ex vivo rabbit larynx as an effective model for analyzing the phonatory process.

[Investigation of Type I Thyroplasty Using Titanium Implant]

OBJECTIVE

The aim of this study was to describe a new titanium thyroplasty medializing implant and evaluate its usefulness.

MATERIAL AND METHOD

Retrospective study of 9 male patients with severe unilateral vocal fold paralysis after aortic-aneurysm surgery who underwent type I thyoplasty with arytenoid adduction under general anesthesia. Preoperative and postoperative glottal closure and voice function were evaluated by acoustic analysis (Jitter %, Shimmer %, NHR), stroboscopic findings, maximum phonation time, mean airflow rate, voice handicap index and computed tomography findings. These tests were evaluated before and 3 months after surgery.

RESULT

All acoustic parameters improved after surgery. In stroboscopic findings, symmetrical mucosal waves were identified in 3 cases. Maximum phonation time prolonged, mean flow rate decreased and voice handicap index improved. In computed-tomography findings, breakage, deformation, dropped and migration of titanium plate were not identified.

CONCLUSION

In surgery of vocal fold paralyzed patient, it is necessary to reconstruct vocal fold in physiological state at the time of phonation. Using the titanium plate developed for this purpose, all patients obtained good vocal improvement.

Reliability of OperaVOX against Multidimensional Voice Program (MDVP)

OBJECTIVE

To evaluate the agreement between OperaVOX and MDVP.

DESIGN

Cross sectional reliability study.

SETTING

University teaching hospital.

METHODS

Fifty healthy volunteers and 50 voice disorder patients had supervised recordings in a quiet room using OperaVOX by the iPod's internal microphone with sampling rate of 45 kHz. A five-seconds recording of vowel/a/was used to measure fundamental frequency (F0), jitter, shimmer and noise-to-harmonic ratio (NHR). All healthy volunteers and 21 patients had a second recording. The recorded voices were also analysed using the MDVP. The inter- and intrasoftware reliability was analysed using intraclass correlation (ICC) test and Bland-Altman (BA) method. Mann-Whitney test was used to compare the acoustic parameters between healthy volunteers and patients.

RESULTS

Nine of 50 patients had severe aperiodic voice. The ICC was high with a confidence interval of >0.75 for the inter- and intrasoftware reliability except for the NHR. For the intersoftware BA analysis, excluding the severe aperiodic voice data sets, the bias (95% LOA) of F0, jitter, shimmer and NHR was 0.81 (11.32, -9.71); -0.13 (1.26, -1.52); -0.52 (1.68, -2.72); and 0.08 (0.27, -0.10). For the intrasoftware reliability, it was -1.48 (18.43, -21.39); 0.05 (1.31, -1.21); -0.01 (2.87, -2.89); and 0.005 (0.20, -0.18), respectively. Normative data from the healthy volunteers were obtained. There was a significant difference in all acoustic parameters between volunteers and patients measured by the Opera-VOX (P < 0.001) except for F0 in females (P = 0.87).

CONCLUSION

OperaVOX is comparable to MDVP and has high internal consistency for measuring the F0, jitter and shimmer of voice except for the NHR.

Type I Thyroplasty in Previously Irradiated Patients

Objectives

(1) Review and report our experience performing medialization thyroplasty (MT) in previously irradiated patients and (2) compare complications and voice outcomes in 2 cohorts (irradiated vs nonradiated) to evaluate safety and efficacy.

Study Design

Case series with chart review.

Setting

Academic medical center.

Subjects

All patients (44 total) who underwent MT from 2011 to 2015.

Methods

Demographic data, complications, and acoustic and subjective voice outcome parameters were collected. The complication rates and voice outcome results were compared between 2 cohorts: patients with a history of radiation to the neck versus those with no radiation history.

Results

There were 7 previously irradiated patients and 37 nonradiated patients, with median follow-up of 314 and 538 days, respectively. One complication was noted in each group, and this complication rate was not significantly different ( P = .26). Both cohorts demonstrated significant postoperative improvement in subjective voice assessment ( P = .04, P < .0001) as well as maximum phonation time ( P = .02, .001) when compared with preoperative data.

Conclusions

Our study suggests that MT can be safely and effectively performed in irradiated patients. We found no statistically significant difference in the safety of performing MT in irradiated versus nonradiated patients, and there was significant improvement in subjective voice parameters and maximum phonation time in both groups. A larger prospective study is required to statistically determine whether the significant improvements in objective parameters seen in the nonradiated group are present in irradiated patients as well.

Outcomes of recurrent laryngeal nerve injury following congenital heart surgery: A contemporary experience

Objective

Injury to the recurrent laryngeal nerve can lead to significant morbidity during congenital cardiac surgery. The objective is to expand on the limited understanding of the severity and recovery of this iatrogenic condition.

Design

A six-year retrospective review of all congenital heart operations at a single institution from January 1, 2008 to December 31, 2013 was performed. All patients with documented vocal cord paralysis on laryngoscopic examination comprised the study cohort. Evaluation of time to vocal cord recovery and need for further surgical intervention was the primary focus.

Results

The incidence of post-operative vocal cord paralysis was 1.1% (32 out of 3036 patients; 95% confidence interval: 0.7–1.5%). The majority were left-sided injuries (71%). Overall rate of recovery was 61% with a median time of 10 months in those who recovered, and a total follow up of 46 months. Due to feeding complications, 45% of patients required gastrostomy tube after the injury, and these patients were found to have longer duration of post-operative days of intubation (median 10 vs. 5 days, p = 0.03), ICU length of stay (50 vs. 8 days, p = 0.002), and hospital length of stay (92 vs. 41 days, p = 0.01). No pre-operative variables were identified as predictive of recovery or need for gastrostomy placement.

Conclusion

Recurrent laryngeal nerve injury is a serious complication of congenital heart surgery that impacts post-operative morbidity, in some cases leading to a need for further intervention, in particular, gastrostomy tube placement. A prospective, multi-center study is needed to fully evaluate factors that influence severity and time to recovery.

Chronic vocal cord palsy in Thuringia, Germany: a population-based study on epidemiology and outcome

Although surgical treatment of patients with chronic vocal cord palsy (VCP) is an integral part of clinical routine of otorhinolaryngologists, there is nearly no population-based data published on incidence and efficiency of this surgery country-wide or nation-wide. 1430 patients with chronic VCP were treated in a department of otorhinolaryngology between 2005 and 2010 in Thuringia, Germany. VCP was unilateral and bilateral in 63 and 18%, respectively. The affected side was not documented in 20%. Iatrogenic lesions of the recurrent nerve (42%) and neoplastic infiltration (27%) were the leading etiologies. 192 patients (13%) received surgical treatment. 31% of patient needed more than one surgery. The rate of surgeries was higher for bilateral VCP (p < 0.0001). Vocal cord augmentation was the most frequent surgery for unilateral VCP and posterior cordectomy for bilateral VCP. The complication rate was high (16%), but not different between unilateral and bilateral VCP (p = 0.108). The risk for tracheostomy was higher in the bilateral VCP group (p < 0.0001). Voice improvement was better after treatment of unilateral VCP (p < 0.0001). Breathing improvement was more frequent after bilateral VCP (p = 0.028). Dysphagia did not improve significantly. The rate of better voice, breathing, and swallowing function was higher in patients treated surgically than without surgery (all p < 0.0001). The rate of patients admitted for treatment of vocal fold palsy was 9.9/100,000 habitants. The surgical rate of VCP was 1.38/100,000 habitants. This population-based analysis shows that surgery for VCP is performed with higher incidence than expected effectively, but with relevant risks in daily routine of otorhinolaryngologists.