Early voice rehabilitation with injection laryngoplasty in patients with unilateral vocal cord palsy after thyroidectomy

Duration of Effect and Associated Factors of Injection Laryngoplasty

OBJECTIVE

Injection laryngoplasty (IL) has become a mainstay in the treatment of unilateral vocal fold paralysis due to technical ease and avoidance of open surgery. The duration of IL effect depends on the injected material and has not been defined clearly. We aimed to define the effective duration of IL and to investigate the associated factors.

METHODS

Fifty-nine patients who underwent IL for unilateral vocal fold paralysis were included. IL was performed using a cricothyroid membrane approach under local anesthesia. During follow-up, in cases that developed subjective hoarseness with objective glottic insufficiency, a second IL was performed, and loss of IL effect was recorded. The duration of IL was analyzed using Kaplan-Meier estimates, and the associations between duration of effect and various factors such as postinjection voice therapy, injected material, and cause of paralysis were investigated using log-rank test.

RESULTS

Of 59 patients, 20 (33.9 %) received a second IL. The median time interval between the first and second IL was 3.3 months (95% CI, 0.4∼27.8 months). The mean duration of effect after IL was 42.5 months (95% CI, 32.1∼52.9 months), and the rate of persisting effect was 63.4% at 1-year after IL (1-year effect rate) and 59.4% at 2 years after IL. The 1-year effect rate was 80.8% in cases with postinjection voice therapy and 57.8% in those without postinjection voice therapy (P = 0.084). Injected material, DM, HTN, patient age and sex, and cause of paralysis had no effect on the 1-year effect rate.

CONCLUSIONS

The mean duration of IL effect was 42.5 months, and the rate of persisting effect was 63.4% at 1-year after IL. There were no significant factors affecting the duration of effect, although the duration tended to be slightly longer in cases with postinjection voice therapy. Further study with a prospective, randomized design is needed.

Dysphagia as a predictor of voice handicap and voice restoration in unilateral vocal fold immobility

OBJECTIVE

Dysphagia is multifactorial in unilateral vocal fold immobility (UVFI). Severe dysphagia could indicate greater functional deficits in UVFI. The purpose of this study is to evaluate the association of dysphagia with the need for surgical voice restoration in patients with UVFI.

STUDY DESIGN

Retrospective chart review.

SETTING

Single-institution, tertiary referral center.

METHODS

Records of UVFI patients from 2008 to 2018 were examined. Dysphagia severity was extracted from patient history. Etiology of UVFI and other relevant variables were analyzed to determine their association with dysphagia. Dysphagia severity and other clinical variables were then analyzed for their association with surgical voice restoration.

RESULTS

Eighty patients met selection criteria out of 478 patients with UVFI. There was significant concordance between dysphagia severity extracted from patient history and patient-reported EAT-10 scores (R = 0.59, p = 0.000035). Patients' EAT-10 scores were correlated with VHI-10 scores (R = 0.45, p = 0.011). Severe dysphagia (p = 0.037), high VHI-10 score on presentation (p = 0.0009), and longer duration of hoarseness before presentation (p = 0.008) were associated with surgical voice restoration in UVFI patients.

CONCLUSION

In this pilot study, severe dysphagia and increased voice handicap on presentation were associated with the need for surgical voice restoration in UVFI patients. Presenting dysphagia may be an additional variable for clinicians to consider for management of UVFI.

Association of Sociodemographic Factors on the Presentation and Management of Unilateral Vocal Fold Immobility

OBJECTIVE

To determine the association of social determinants of health (SDOH) on the presentation and management of unilateral vocal fold immobility (UVFI).

METHODS

Retrospective chart review of 207 adult UVFI patients evaluated at a tertiary-care hospital between 2018 and 2019 was performed. Sociodemographic factors including gender, median household income, preferred language, and insurance type were recorded. Confounding clinical factors including etiology of UVFI, Voice Handicap Index-10 (VHI-10) score, laryngoscopic findings, and intervention history were extracted from medical records. Multivariable logistic regression was performed using sociodemographic and clinical factors.

RESULTS

Patient demographics and socioeconomic status were not associated with time to presentation. Patients presenting with glottic insufficiency and UVFI due to malignancy or recurrent laryngeal nerve (RLN) sacrifice had a shorter time to presentation. Higher household income was associated with greater number of interventions (p = 0.02), but neither income nor insurance type affected intervention type or timing. Female patients were less likely to undergo injection medialization laryngoplasty (odds ratio [OR] 0.25, p = 0.005). Older patients were more likely to undergo injection (OR 1.04, p = 0.027). Patients with large glottic gaps (OR 21.2, p = 0.014) and higher VHI-10 scores (OR 1.06, p = 0.047) were more likely to undergo surgery.

CONCLUSION

Higher household income was associated with greater number of interventions and longer duration of care at a private tertiary-care hospital. RLN sacrifice, known malignancy, and glottic insufficiency significantly reduced the time to presentation. Type of intervention received was a complex interplay of both demographic and clinical factors. Large prospective studies should examine the role of SDOH in the presentation and management of UVFI.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:297-304, 2024.

Analysis of the Outcomes of Immediate Recurrent Laryngeal Nerve Reconstruction During Thyroid Surgery for Prevention of Vocal Fold Paralysis

BACKGROUND

Recurrent laryngeal nerve (RLN) injury and the resulting paralysis is the most common and known complication of thyroid surgery. Several surgical techniques, such as medialization thyroplasty with or without arytenoid adduction and injection laryngoplasty, have been developed to treat RLN injury, but these procedures have specific limitations and complications. In this study, we present the outcomes for our patients who underwent immediate RLN reconstruction during thyroid surgery by analyzing both subjective and objective outcomes.

METHODS

A retrospective study was conducted for patients who underwent total or subtotal thyroidectomy between May 2012 and March 2020. Among them, patients who underwent immediate RLN reconstruction due to unilateral RLN injury were followed for at least 12 months. The voice perceptual evaluation, acoustic analysis, voice range profile, and Voice Handicap Index (VHI) scores were obtained preoperatively, 1 month, 6 months, and 12 months after surgery.

RESULTS

Among the 11 patients, 6 patients (54.5%) underwent direct anastomosis, and 5 patients (45.5%) underwent nerve grafts using ansa cervicalis and great auricular nerve. The grade and breathiness in the GRBAS (grade, roughness, breathiness, asthenia, and strain) scale and jitter item showed significant improvement at 12 months postoperatively, and although not statistically significant, the rest of the items also tended to improve. The total, functional, and physical scores on VHI improved significantly at 12 months postoperatively. Moreover, when comparing the voice analysis of the direct anastomosis group and the nerve graft group, there was no significant difference between the groups in objective and subjective results.

CONCLUSION

Immediate RLN reconstruction demonstrated significant voice improvement postoperatively, and reconstructing the nerve immediately and combining follow-up treatment in the event of RLN injury will greatly help patients improve their long-term voice outcomes.

The Additive Effectiveness of Inspiratory Muscle Training on Glottic Closure and Subjective Voice Outcomes of Patients With Benign Lesion After Hyaluronic Acid Laryngoplasty

OBJECTIVES

For patients with glottic insufficiency disease, injection laryngoplasty is a rapid and efficient management option that complements voice therapy. Some studies have indicated that respiratory muscle training may also show promise in patients with voice disorders. However, the effect of respiratory muscle training in patients with glottic insufficiency was reported to be limited, and whether it provides additional benefit after standard management requires further evaluation. We aimed to investigate the effectiveness of inspiratory muscle training on glottis closure and patient-reported voice quality in glottic insufficiency patients who had been treated with hyaluronic acid injection.

STUDY DESIGN

Retrospective observational study.

METHODS

We included 46 patients with glottic insufficiency who had undergone hyaluronic acid injection. Twenty of them had undergone inspiratory muscle training during three months. We measured patients' changes in glottic status according to the normalized glottal gap area and bowing index, as well as voice quality of life according to the voice handicap index 10 and the voice outcome survey, before and after training.

RESULTS

Patients who underwent inspiratory muscle training had higher odds of experiencing better improvement in all scores. The range of odds ratios ranged from 2.5 to 6.3 for changes in scores, and from 3.8 to 22.2 for changes in score percentages. Of note, the effect of training on percentage changes in the normalized glottal gap area score was significant (P= 0.0127) after adjustment for the duration of vocal disease, body mass index and BMI, and history of gastroesophageal reflux disease.

CONCLUSIONS

Inspiratory muscle training can improve the glottal gap after injection laryngoplasty, and may be applied in clinical practice.

Office-Based Structural Autologous Fat Injection Laryngoplasty for Unilateral Vocal Fold Paralysis

Unilateral vocal fold paralysis (UVFP) is a common cause of incomplete glottic closure, leading to significant somatic and social disabilities. Office-based autologous fat injection laryngoplasty (AFIL) has been proposed as an effective treatment for glottic insufficiency but has not been well-studied for UVFP. We enrolled 23 patients who underwent office-based structural AFIL due to unilateral vocal paralysis at our institution between February 2021 and January 2022. In the procedure, autologous fat was harvested and injected into the vocal fold under the guidance of flexible digital endoscopy for structural fat grafting. The voice handicap index-10 (VHI-10) score and perceptual voice measurements were collected before the operation, 2 weeks postoperatively, and 3 months postoperatively. Twenty-two patients were followed-up for at least 3 months. The VHI-10 score improved significantly from 29.65 ± 8.52 preoperatively to 11.74 ± 7.42 at 2 weeks (p < 0.0001) and 5.36 ± 6.67 at 3 months (p < 0.0001). Significant improvements in grades of dysphonia (p < 0.0001), breathiness (p < 0.0001), and asthenia (p = 0.004) were also noted at 3 months postoperatively when perceptual measurements were investigated. Office-based structural AFIL is an effective treatment for improving voice-related disability for UVFP patients.

Management of Unilateral Vocal Fold Paralysis after Thyroid Surgery with Injection Laryngoplasty: State of Art Review

Background

Unilateral vocal fold paralysis (UVFP) after thyroid surgery often leads to significant morbidity including dysphonia, dysphagia, and aspiration. Injection laryngoplasty (IL) is an effective treatment of UVFP with numerous readily available materials. However, few studies focus on IL for UVFP following thyroidectomy.

Objectives

This review aims to critically review current literature to determine the timing, materials, methods and outcomes of IL for UVFP after thyroid surgery.

Type of Review

Literature review.

Methods

A literature review was performed using the Pubmed, Medline and EMBASE databases. All relevant articles published in English addressing the effect of IL in post thyroid surgery related UVFP were analyzed. Studies using IL for UVFP of multiple etiologies were excluded. Meta-analysis was conducted using fixed and random effect model.

Results

Five original studies were identified, including 214 patients received IL for UVFP following thyroid surgery. Two studies injected autologous fat via direct suspension laryngoscope under general anesthesia, while the other 3 studies injected polyacrylamide, hyaluronic acid, and polymethyl methacrylate from cricothyroid membrane under local anesthesia. All 5 studies reported improved voice outcomes of IL for post-thyroidectomy UVFP. Meta-analysis showed MPT increased for 3.18 s (95% CI: 2.40-3.96, fix effect model) after IL. Another common acoustic parameter, jitter (%) also improved for 1.46 (95% CI: 0.73-2.19, random effects model) after IL for post-thyroidectomy UVFP.

Conclusions

This review supported that IL can improve the voice outcome for post-thyroidectomy UVFP. Autologous fat remains a good augmentation material with a potential longer lasting effect. More research and long-term surveys are needed to document the safety and longevity of other synthetic materials.

Effects of Sequentially Combined Arytenoid Adduction and Injection Laryngoplasty in Patients With Unilateral Vocal Fold Paralysis

OBJECTIVES

Arytenoid adduction (AA) and injection laryngoplasty (IL) are major surgical options for the treatment of unilateral vocal fold paralysis (UVFP). AA is a laryngeal framework surgery and IL is a soft-tissue augmentation procedure. Therefore, the effect of each intervention will not be substitutive but complementary to the other.

METHODS

Patients who received AA and IL were enrolled (N = 43). Mean age was 60.1 ± 12.7 years. Objective and subjective voice parameters including maximum phonation time (MPT), jitter, shimmer, noise to harmonic ratio (NHR), grade of dysphonia (G), and voice handicap index (VHI)-30 were collected preoperatively and 6 months postoperatively. AA and IL were sequentially performed with time interval; 28 (65.1%) patients received IL first followed by AA (IL+AA group) and 15 (34.9%) had AA followed by IL (AA+IL group). Time interval between first and second procedures was 9.9 ± 14.6 months.

RESULTS

MPT, jitter, shimmer, NHR, G and VHI-30 significantly improved by both first and second procedures (P < 0.001). When we evaluated IL+AA group and AA+IL group separately, the final outcomes of MPT, jitter, G, and VHI-30 between the two groups were not significantly different. When the overall effects of IL and AA were compared, MPT significantly improved with AA than with IL (P < 0.001).

CONCLUSION

In patients with unilateral vocal fold paralysis, sequential AA and IL (or IL and AA) provided additional improvement of subjective and objective voice parameters. Final outcomes of the two combined procedures resulted in similar degree of voice improvement regardless of the order of procedure.

LEVEL OF EVIDENCE

4.

[Update on vocal fold augmentation]

Unilateral vocal fold palsy is a frequent cause of hoarseness. In the presence of glottis closure insufficiency, the effectiveness of conservative voice therapy is often limited and phonosurgery may be indicated. Injection laryngoplasty is effective for correction of insufficiency. Early intervention during the first 6 months after diagnosis is desired to avoid subsequent insufficient endogenous compensation. Particularly patients with glottic closure insufficiency ≤2 mm in stroboscopy may benefit from this procedure. With appropriate patient selection, duration of the effect exceeding 12 months has been described for hyaluronic acid, calcium hydroxylapatite, and autologous fat. Due to rare complications such as allergic swelling at the injection site, regular laryngoscopic monitoring and observation for two nights after injection are recommended. The voice must only be rested for a few hours.

Voice outcome after vocal fold injection augmentation with carboxymethyl cellulose versus calcium hydroxyapatite

BACKGROUND

Vocal fold injection augmentation is a recognised treatment modality for glottic insufficiency. Causes of glottal closure insufficiency include vocal fold paralysis, paresis, atrophy, sulcus vocalis, scarring and vocal fold deficiency after laryngeal surgery. A variety of materials exist for injection augmentation. This study aimed to compare voice improvement after injection augmentation between two injectable materials: carboxymethyl cellulose and calcium hydroxyapatite.

METHOD

This retrospective study included 66 consecutive patients with glottic insufficiency who underwent injection augmentation.

RESULTS

Among the patients who received their first injection augmentation with carboxymethyl cellulose and their second injection augmentation with calcium hydroxyapatite (n = 28), voice quality improved significantly after both injection augmentations. No significant differences were observed in any of the objective and subjective voice quality measurements examined following carboxymethyl cellulose and calcium hydroxyapatite injections.

CONCLUSION

Voice improvement after injection augmentation depends mainly on the improvement of glottic closure, rather than the injection material.

Early Injection Laryngoplasty With a Long-Lasting Material in Patients With Potentially Recoverable Unilateral Vocal Fold Paralysis

Objectives.

Injection laryngoplasty (IL) is one of the major options for treatment of unilateral vocal fold paralysis (UVFP). Early IL in patients with abrupt-onset UVFP can reduce hoarseness and aspiration-related discomfort and complications. Temporary or short-lasting materials are recommended for the early IL since permanent or long-lasting materials may negatively affect the voice quality when vocal fold motion is spontaneously recovered.

Methods.

Patients who received IL with a long-lasting material (ArteSense) within 1 month following development of postoperative UVFP were enrolled for this study. They were categorized into a spontaneously recovered group (n=30) and unrecovered group (n=276) from UVFP. The subjective and objective voice parameters were collected before and 6 months after IL. Patients’ demographics and collected voice parameters were compared between the two groups.

Results.

Age and sex distributions were not different between the two groups. Aspiration symptom, maximum phonation time (MPT), jitter, shimmer, noise to harmonic ratio (NHR), overall grade (G) and breathiness (B) of GRBAS (grade of dysphonia, roughness, breathiness, asthenia, strain) scale score, and voice handicap index (VHI) were significantly improved after IL in both groups. The amounts of improvement in MPT, jitter, shimmer, NHR and VHI were significantly greater in the recovered group. There was no IL-related complication including granuloma formation, hypersensitivity to injection material, or worsening of hoarseness.

Conclusion.

Early IL with a long-lasting material can be safely performed to improve voice quality and to reduce aspiration episode for the patients with postoperative UVFP, regardless of recovery from the paralysis. The amounts of improvement in the subjective and objective voice parameters were significantly greater in patients who showed spontaneous recovery from UVFP when compared with those in patients who did not.

Perspectives on voice treatment for unilateral vocal fold paralysis

PURPOSE OF REVIEW

Unilateral vocal fold paralysis (UVFP) is a common cause of neurogenic dysphonia resulting in glottal insufficiency. To restore glottal sufficiency and reduce the presenting dysphonia, treatment involving either surgical intervention, voice therapy or a combination of the two is typically provided. Currently, there is no consensus for the most effective voice treatment for UVFP. This results in an inability to compare current studies, and a lack of treatment effectiveness for the management of UVFP. This study aims to review the most recent literature for the management of dysphonia due to UVFP to establish the current evidence base for voice treatment options.

RECENT FINDINGS

There was found to be a lack of consistency in the rationale, selection and timing of the surgical intervention and/or voice therapy being provided for patients with UVFP.

SUMMARY

Further consensus is required for the rationale and selection of voice treatment prescriptions for the management of UVFP in order to improve treatment effectiveness and voice outcomes in patients with UVFP.

Voice outcome indicators for unilateral vocal fold paralysis surgery: a review of the literature

INTRODUCTION

There is no consensus on which voice outcome indicators (VOIs) should be used to compare the merits of the various surgical treatments for unilateral vocal fold paralysis (UVFP). Authors performed a literature review to identify which VOIs are most frequently used and most relevant, in terms of significant change in pre- and post-operative measurements, to assess UVFP surgical treatments.

METHOD

A Medline/Pubmed literature review was performed and the most frequently used VOIs were identified using a Pareto diagram. For these most frequently used VOI's, the number of studies that showed a statistically significant change in pre- and post-operative results were compared to the total number of studies found using that same VOI, this portion was expressed in percent. This percentage was defined as the "percentage of significance" and used to assess changes of each VOI.

RESULTS

Eleven VOIs were identified using the Pareto analysis. These were, in decreasing order of frequency of citation: maximum phonation time (MPT), jitter, Shimmer, video-stroboscopic examination, noise to harmonic ratio (NHR/HNR), mean air flow (MeAF), fundamental frequency (F0), "Infrequent Perceptional Scales", GRBAS scale, mean subglottic pressure (MSGP). MPT, MeAF, factor G of GRBAS-I, Jitter, shimmer and VHI-30 had respective "percentage of significance" of 90, 86, 85, 74, 68 and 64%, respectively.

CONCLUSION

The results indicate that MPT, MeAF and GRBAS-I, represent the top-three most frequently used and the most relevant VOIs in terms of "percentage of significance". VHI-30 showed a relatively low rate of use and low "percentage of significance". The role of Jitter and Shimmer remains unclear. Finally, MSGP and the F0 appear to be less relevant VOIs for the evaluation of UFVP surgical treatments in terms of significant change in pre- and post-operative measurements.

Speech therapy after thyroidectomy

Common complaints of patients who have received thyroidectomy include dysphonia (voice dysfunction) and dysphagia (difficulty swallowing). One cause of these surgical outcomes is recurrent laryngeal nerve paralysis. Many studies have discussed the effectiveness of speech therapy (e.g., voice therapy and dysphagia therapy) for improving dysphonia and dysphagia, but not specifically in patients who have received thyroidectomy. Therefore, the aim of this paper was to discuss issues regarding speech therapy such as voice therapy and dysphagia for patients after thyroidectomy. Another aim was to review the literature on speech therapy for patients with recurrent laryngeal nerve paralysis after thyroidectomy. Databases used for the literature review in this study included, PubMed, MEDLINE, Academic Search Primer, ERIC, CINAHL Plus, and EBSCO. The articles retrieved by database searches were classified and screened for relevance by using EndNote. Of the 936 articles retrieved, 18 discussed "voice assessment and thyroidectomy", 3 discussed "voice therapy and thyroidectomy", and 11 discussed "surgical interventions for voice restoration after thyroidectomy". Only 3 studies discussed topics related to "swallowing function assessment/treatment and thyroidectomy". Although many studies have investigated voice changes and assessment methods in thyroidectomy patients, few recent studies have investigated speech therapy after thyroidectomy. Additionally, some studies have addressed dysphagia after thyroidectomy, but few have discussed assessment and treatment of dysphagia after thyroidectomy.

Injection laryngoplasty as miniinvasive office-based surgery in patients with unilateral vocal fold paralysis - voice quality outcomes

Introduction

Injection laryngoplasty (glottis augmentation) is the preferred method in surgical management of unilateral vocal fold paralysis (UVFP). Traditionally, these procedures are performed in the operating room. Nowadays, however, these procedures have moved into the office.

Aim

To evaluate the voice quality after transoral injection laryngoplasty under local anaesthesia in patients with unilateral vocal fold paralysis.

Material and methods

Fourteen subjects (5 women and 9 men) with unilateral vocal fold paresis (9 with right vocal fold paresis and 5 with left vocal fold paresis) were included in the study. The mean age of the group was 57.8 ±19.0 years (32–83 years). All of the injection laryngoplasties were performed transorally, under local anaesthesia. The injection material was calcium hydroxylapatite. Before and 1, 3 and 6 months after the procedure the following variables were evaluated: voice perception, videostroboscopy, acoustic analysis, aerodynamic evaluation, and the subjective rating of the voice quality by the patient.

Results

After injection laryngoplasty, complete glottal closure was achieved or there was a significant improvement in the glottal closure of each subject. We noted great improvement in the post-injection objective and subjective voice outcomes and patients reported improvement in the voice-related quality of life.

Conclusions

The transoral approach for injection laryngoplasty under local anaesthesia is an effective and safe way to treat incomplete glottal closure in patients with UVFP. The transoral approach is an efficient alternative to other surgical techniques used for vocal fold injection.

One hundred years of external approach medialisation thyroplasty

It has been 100 years since Erwin Payr first developed an operation to improve the effects of a paralysed vocal fold, and operations based on this technique are still in use today. This technique, medialisation thyroplasty, aims to improve the symptoms caused by vocal fold palsy by realigning the lateralised vocal fold into the midline.

Whilst the effects of vocal fold palsy were recognised in antiquity, it was only with the development of indirect laryngoscopy in the late nineteenth century that the vocal fold paralysis could be identified as an aetiology for poor phonation and dysphagia. Payr, in 1915, was the first to perform a recognisable form of medialisation thyroplasty, which was further developed in the early twentieth century, but medialisation thyroplasty did not begin to be widely used until the development of the modern technique by Isshiki et al., in 1974.

Since then, medialisation thyroplasty has continued to be developed and is currently the most widely used technique for correcting the effects of vocal fold palsy. However, a wide array of therapeutic options is now available for vocal fold palsy and it is impossible to say whether or not medialisation thyroplasty will still be used in another 100 years.