Hyaluronidase Injection in the Vocal Folds for Vocal Hemorrhage, Reinke Edema, and Hyaluronic Acid Overinjection: A Novel Application in the Larynx

Hydration State and Hyaluronidase Treatment Significantly Affect Porcine Vocal Fold Biomechanics

OBJECTIVES

The understanding of vocal fold hydration state, including dehydrated, euhydrated, rehydrated tissue, and how hydration affects vocal fold biomechanical properties is still evolving. Although clinical observations support the benefits of increasing vocal fold hydration after dehydrating events, more mechanistic information on the effects of vocal fold dehydration and the beneficial effects of rehydration are needed. Alterations to hyaluronic acid (HA), an important component of the vocal fold extracellular matrix, are likely to influence the biomechanical properties of vocal folds. In this study, we investigated the influence of hydration state and HA on vocal fold tissue stiffness via biomechanical testing.

STUDY DESIGN

Prospective, ex vivo study design.

METHODS

Fresh porcine vocal folds (N = 18) were examined following sequential immersion in hypertonic (dehydration) and isotonic solutions (rehydration). In a separate experiment, vocal folds were incubated in hyaluronidase (Hyal) to remove HA. Control tissues were not exposed to any challenges. A custom micromechanical system with a microforce sensing probe was used to measure the force-displacement response. Optical strain was calculated, and ultrasound imaging was used to measure tissue cross-sectional area to obtain stress-strain curves.

RESULTS

Significant increases (P ≤ 0.05) were found in tangent moduli between dehydrated and rehydrated vocal folds at strains of ε = 0.15. The tangent moduli of Hyal-digested tissues significantly increased at both ε = 0.15 and 0.3 (P ≤ 0.05).

CONCLUSION

Vocal fold dehydration increased tissue stiffness and rehydration reduced the stiffness. Loss of HA increased vocal fold stiffness, suggesting a potential mechanical role for HA in euhydrated vocal folds.

Office-based blue laser therapy for dyspnea in patients with type 3 Reinke's edema

PURPOSE

To investigate the effectiveness of in-office blue laser therapy on dyspnea in patients with type 3 Reinke's edema.

METHODS

The medical records and video-recordings of patients with Reinke's edema type 3 who had undergone office-based blue laser therapy between March 2022 and January 2023 were reviewed. The primary outcome measures assessed before and after surgery were dyspnea severity, risk of obstructive sleep apnea (OSA), and disease regression. The severity of dyspnea was measured using the Dyspnea Severity Index (DSI), the risk of OSA was assessed using the STOP-BANG questionnaire, and disease regression was assessed by reviewing the laryngeal examination before and after surgery. The Voice Handicap Index-10 (VHI-10) was used as a secondary outcome measure.

RESULT

A total of 10 patients were included. The mean age of the study population was 58.9 ± 4.2 years. The male-to-female ratio was 2:3. In total, 20 vocal fold lesions were treated among which 18 were reviewed. Eight lesions regressed completely and 10 partially. There was a statistically significant drop in the mean score of DSI after surgery (16.1 ± 10.2 pre-operatively vs 2.3 ± 2.3 post-operatively, p-value < 0.001). The mean STOP-BANG score decreased from 4.8 ± 1.47 to 3.1 ± 1.28 (p-value = 0.001). There was also a significant improvement in VHI-10 score (22.7 ± 7.0 vs 4.4 ± 5.6, p-value < 0.001).

CONCLUSION

Office-based blue laser therapy offers a safe and effective treatment for shortness of breath in patients with type 3 Reinke's edema.

Unsedated Office-Based Blue Laser Therapy in Female Patients With Reinke's Edema: A Retrospective Review of 8 Cases

OBJECTIVES

To report on the outcomes of unsedated blue laser therapy in female patients with Reinke's edema.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review of female patients undergoing unsedated office-based blue laser treatment of Reinke's edema between February 2020 and March 2022 at the Hamdan Voice and Swallowing Unit at the American University of Beirut Medical Center in Beirut, was conducted. Patients were assessed before and after the procedure with a follow-up interval of 3-6 weeks. Demographic data included age, history of smoking and grade of Reinke's edema. Voice outcome measures included the Voice Handicap Index-10 questionnaire, perceptual evaluation (GRBAS scale), acoustic analysis and maximum phonation time. Vocal fold lesions were evaluated using indirect laryngeal endoscopy.

RESULTS

A total of eight patients were reviewed. The mean age was 59.63 ± 7.98 years. One patient was lost to follow-up. We report on a total of 10 Reinke's edema lesions treated with the blue laser. There was a significant decrease in the mean VHI-10 score (14.86 ± 5.84-6.71 ± 7.32; P < 0.01) as well as in the means of three perceptual evaluation parameters (G, R, B; P < 0.05). There was also a nonstatistically significant increase in the mean fundamental frequency and habitual pitch. Laryngeal examination showed complete regression in 50% of the lesions, and partial regression in the remaining 50%.

CONCLUSIONS

Office-based blue laser treatment of Reinke's edema under local anesthesia can be considered an effective treatment modality as evidenced by improvement in post-procedure voice outcome measures.

Reinke's edema management and voice outcomes

Objectives

Reinke's edema is a chronic disease of the respiratory tract that occurs in adults with a history of chronic smoke exposure. Also known as polypoid corditis, polypoid laryngitis, and polypoid degeneration of the vocal fold, it is strongly associated with smoking, frequently with vocal misuse/abuse, and occasionally with laryngopharyngeal reflux. Reinke's edema remains a cause of chronic dysphonia that is difficult to manage. This review provides perspectives on current and future management of Reinke's edema.

Results

Reinke's edema impacts <1% of the population. The excessive mass is seen in polypoid degeneration results in a loss of pitch control and a rough voice. Women are more likely to present for treatment as the characteristic lowering of vocal pitch is more noticeable in women than men. Multiple grading systems have been proposed within the literature. The current standard of care is surgical excision, after smoking cessation. The microflap technique remains the approach of choice for bulky lesions. Surgical management of Reinke's edema has evolved with the introduction of various lasers into otolaryngologic practice; some which can now be used in the office setting. While many management approaches have been described within the literature, there is a little direct comparison and no obvious superior method of Reinke's edema management.

Conclusion

To date, the biology of Reinke's edema is not well understood. Additional research is needed further elucidate the role of uncontrolled reflux in the development and recurrence of Reinke's edema.

Phonosurgery of Reinke's edema with microdebrider

PURPOSE

To present our experience with a new microsurgical approach for treatment of the Reinke's edema in suspension laryngoscopy-microdebridement. After a short review of existing literature we introduce speech therapy before and after the surgery into the protocol.

METHODS

 The authors compare the phonatory outcome, laryngostroboscopical results and subjective improvement of the voice of 30 patients with Reinke's edema that were operated with either microdebridement or cold steel surgery techniques. "Sandwich" speech therapy strategy was applied for the vocal rehabilitation before and after surgery in both patient groups.

RESULTS

After the microdebridement and the speech therapy the mucosal wave was regular, symmetric and periodic in all patients. No signs of abnormal scar tissue or anterior adhesions were observed. Significant improvement of vocal parameters was found after the surgery in both groups of patients: operated with the microdebridement technique and the cold steel technique. The subjective voice evaluated by Voice Handicap Index (VHI-10) was improved for both patient groups in a homogenous way.

CONCLUSIONS

Based on the similarity of the vocal outcome in the two groups, microdebridement of the vocal folds is an excellent method for removing the edema of the Reinke's space. Careful suction at a low voltage protects the lamina propria during the microdebridement. The authors discuss the indication to this innovating procedure in patients with difficult laryngeal exposure and small operating field.

Real-time Light-guided Vocal Fold Injection via Cricothyroid Membrane in Unilateral Vocal Fold Paralysis: A Human Pilot Study

Objectives.

Vocal fold injection (VFI) via the cricothyroid (CT) membrane is used to treat various diseases affecting the vocal folds. The technical challenges of this technique are mainly related to the invisibility of the needle. Real-time light-guided VFI (RL-VFI) was recently developed for injection under simultaneous light guidance in the CT approach. Herein, we present the first clinical trial of RL-VFI, in which we investigated the feasibility and safety of this new technique in unilateral vocal fold paralysis (VFP).

Methods.

This prospective pilot study enrolled 40 patients, who were treated with RL-VFI for unilateral VFP between September 2020 and August 2021. Adverse events were monitored during the procedure and for 4 weeks postoperatively. The Voice Handicap Index-10, the GRBAS (grade, roughness, breathiness, asthenia, and strain) scale, aerodynamic studies, and acoustic analyses were evaluated to compare the voice improvement after 4 weeks with the baseline values.

Results.

The needle tip was intuitively identified by the red light. The mean procedure time was 95.6±40.6 seconds for the initial injection, while the additional injection required 79.2±70.5 seconds. The injection was performed under light guidance without additional manipulation after the needle reached the intended point. No acute or delayed adverse events were reported. Among the 40 patients, 36 completed voice analyses after 4 weeks. Subjective and objective voice parameters, including the Voice Handicap Index-10, GRBAS scale, maximum phonation time, mean expiratory airflow, fundamental frequency, jitter, shimmer, and noise-to-harmonics ratio improved significantly after RL-VFI (P<0.05), while the expiratory volume was maintained.

Conclusion.

RL-VFI is feasible and safe for treating patients with unilateral VFP. This technique is anticipated to improve the precision and safety of the CT approach in the treatment of unilateral VFP. This study provides a rationale for further structured clinical studies.

Prolonged persistence of hyaluronic acid after suboptimal vocal fold injection

Hyaluronic acid (HA) is a commonly used injectable material in temporary vocal fold injections (VFI) in patients with unilateral vocal fold paralysis (UVFP). Hyaluronic acid has generally been known for its three-six months of longevity following VFI. Owing to recent advances in cross-linking technologies, the longevity of HA-based materials, including deep-volumizing cross-linked HA used in VFI, has been improved. However, persisting injectable material in the subepithelial space poses undesirable complications following VFI. Herein, we report 2 cases of unexpected persistence of superficially injected cross-linked HA. In the first case, a 70-year-old man with iatrogenic UVFP received VFI with cross-linked HA three years ago and was referred for persistent dysphonia. Previously injected HA spilled out from the vocal fold (VF) when an epithelial incision was made in the subepithelial cystic lesion. In the second case, a 72-year-old woman with iatrogenic UVFP received VFI with cross-linked HA that migrated into the subepithelial space. Diffuse swelling of the injected VF caused dysphonia that lasted for a year. The previously injected HA spilled out when an epithelial incision was made in the swollen VF. Since superficially injected deep-volumizing cross-linked HA can persist for up to three years, laryngologists should be aware of possible sequelae upon suboptimal VFI with cross-linked HA.

Exploring the Pathophysiology of Reinke's Edema: The Cellular Impact of Cigarette Smoke and Vibration

Objectives

To explore the isolated or combined effects of cigarette smoke extract (CSE) and vibration on human vocal fold fibroblasts (hVFF) in an in vitro setting in order to elucidate their influence in the pathophysiology of Reinke's edema (RE).

Study design

Immortalized hVFF were exposed to CSE or control medium under static or vibrational conditions. A phonomimetic bioreactor was used to deliver vibrational patterns to hVFF over a period of 5 days.

Methods

Cytotoxicity was quantified using a lactate dehydrogenase assay. We employed reverse transcription–quantitative polymerase chain reaction, enzyme‐linked immunosorbent assay, and Magnetic Luminex^(R) assays (R&D Systems, Minneapolis, MN) to assess the influence on extracellular matrix production, fibrogenesis, inflammation, and angiogenesis.

Results

We observed significant changes induced by CSE alone (hyaluronic acid, matrix metalloproteinase 1, Interleukin‐8, cyclooxygenase [COX]1, COX2, vascular endothelial growth factor [VEGF]D), as well as settings in which only the combination of CSE and vibration led to significant changes (transforming growth factor beta 1, VEGFA, VEGFC). Also, CSE‐induced levels of COX2 were only significantly reduced when vibration was applied.

Conclusion

We were able to explore the cellular effects of CSE and vibration on hVFF by employing a phonomimetic bioreactor. Whereas cigarette smoke is generally accepted as a risk factor for RE, the role of vibration remained unclear as it is difficult to study in humans. Our data showed that some genes and proteins in the pathophysiological context of RE were only affected when CSE in combination with vibration was applied.

Level of Evidence

NA Laryngoscope, 131:E547–E554, 2021

Unsedated Office-Based Thulium Laser Therapy in Patients With Reinke's Edema

OBJECTIVE

To report the outcome of unsedated office based Thulium laser therapy for Reinke's edema.

MATERIALS AND METHODS

A retrospective chart review of patients operated between March 2017 and November 2018 was conducted. Twelve patients were included, two of whom had two procedures performed. Demographic data included age, gender, smoking status, and grade of Reinke's edema. Outcome measures included Voice Handicap Index-10 (VHI), perceptual evaluation, extent of disease regression, acoustic analysis, and maximal phonation time.

RESULTS

Twelve patients were enrolled in this study, one of whom was lost for follow-up. There were eight females and three males. The mean age was 51.27 ± 9.12 years. Endoscopic evaluation 6-12 weeks after surgery revealed complete and partial regression of disease in three and eight patients, respectively. There was a significant improvement in the mean score of VHI-10 (15.00 ± 9.45 vs 3.07 ± 3.81) and the mean score of GRABS parameters following surgery (P < 0.05). The mean habitual pitch increased from 125.11 ± 28.48 Hz to 155.86 ± 55.14 Hz (P = 0.070). There was improvement in the mean jitter and shimmer but none reached a statistical significance. There was no significant change in the mean Maximum phonation time (MPT) scores before and after surgery.

CONCLUSION

Unsedated office-based Thulium laser therapy can be considered as an alternative therapy to patients with Reinke's edema who are not willing to undergo conventional microlaryngeal surgery.

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

OBJECTIVES/HYPOTHESIS

In recent years, basic fibroblast growth factor (bFGF) injection has been used in the treatment of aging-related vocal fold atrophy. This injection not only improves closure by increasing the mass of the vocal fold but also improves its viscoelasticity. However, it has been reported that fibroblasts targeted by bFGF treatment decrease in number with age. The purpose of this study was to examine the effects of local injection of bFGF on age-related vocal atrophy as well as the influence of age on phonological outcomes.

STUDY DESIGN

Retrospective chart review.

METHODS

Fifty-three patients with age-related vocal fold atrophy underwent single injections of bFGF in their vocal folds. Phonological outcomes were evaluated 3 and 6 months after injection by acoustic and aerodynamic measurements.

RESULTS

Voice Handicap Index (VHI), maximum phonation time (MPT), jitter, shimmer, and pitch range improved after injection, and the effects continued for 6 months. In those over 70 years of age, VHI and MPT showed improvement at 3 and 6 months after injection. In addition, the degree of improvement in VHI and MPT did not differ significantly between those older than 70 years and those younger than 70 years.

CONCLUSIONS

Regenerative treatments dependent on bFGF single injection was safe and effective for both early and late elderly patients suffering of vocal fold atrophy.

LEVEL OF EVIDENCE

2c Laryngoscope, 2020.

Surgical and Nonsurgical Lines of Treatment of Reinke's Edema: A Systematic Literature Review

OBJECTIVES

The aim of this study was to carry out a systematic review of different surgical and nonsurgical lines of treatment of Reinke's edema to identify the effectiveness and the guidelines described to use each of them.

METHODS

We searched PubMed and Coherence for randomized controlled trials and case reports studies did on adult humans aged from 18 to 80 years, from January 1997 to December 2018. We included studies that treated patients with Reinke's edema by one and/or combinations of the following interventions: cold steel microlaryngeal phonosurgery, microdebrider, CO₂ laser, photoangiolytic laser, voice therapy, Steroid and Hyaluronidase injection. We selected studies that assessed patients pre- and post-treatment by at least one of the following measures: subjective assessment of the patient's voice by the voice handicap index, perceptual analysis of the voice by GRBAS scale, video laryngeoscopic examination of the VFs and the lesion, aerodynamic measures, and acoustic analysis of the voice by the computerized speech lab. We assessed quality of the included studies with the Cochrane risk of bias assessment Tool.

RESULTS

After removal of duplicates, research yielded 262 studies. Of 217 abstracts and titles, 36 full-text articles were read, and one study was added through hand search, resulting in 10 included studies.

CONCLUSIONS

Most of literature analyzed were deficient to address the effectiveness of any of the six lines included in this study. This is mainly due to the small number of the included articles and the small sample size in most of these studies. We found only 10 articles that reported the effectiveness based on comparing the results of before and after treatment. In addition, the variability of outcome measures used and the lack of the comprehensive assessment of the patient's voice, vocal image in most of the included studies made it hard to us to compare the results of any of the included studies. More researches with larger sample size and accurate randomization are needed for further accurate assessment of the effectiveness of the surgical and nonsurgical lines of treatment of Reinke's edema. The future researches should take in their consideration the use of an agreed comprehensive assessment protocol for assessing and comparing the outcome measures before and after treatment.

Proteomic Analysis of Vocal Fold Fibroblasts Exposed to Cigarette Smoke Extract: Exploring the Pathophysiology of Reinke's Edema

Reinke's edema is a smoking-associated, benign, mostly bilateral lesion of the vocal folds leading to difficulties in breathing and voice problems. Pronounced histological changes such as damaged microvessels or immune cell infiltration have been described in the vocal fold connective tissue, the lamina propria Thus, vocal fold fibroblasts, the main cell type of the lamina propria, have been postulated to play a critical role in disease mediation. Yet information about the pathophysiology is still scarce and treatment is only surgical, i.e. symptomatic. To explore the pathophysiology of Reinke's edema, we exposed near-primary human vocal fold fibroblasts to medium conditioned with cigarette smoke extract for 24 h as well as 4 days followed by quantitative mass spectrometry.Proteomic analyses after 24 h revealed that cigarette smoke increased proteins previously described to be involved in oxidative stress responses in other contexts. Correspondingly, gene sets linked to metabolism of xenobiotics and reactive oxygen species were significantly enriched among cigarette smoke-induced proteins. Among the proteins most downregulated by cigarette smoke, we identified fibrillar collagens COL1A1 and COL1A2; this reduction was validated by complementary methods. Further, we found a significant increase of UDP-glucose 6-dehydrogenase, generating a building block for biosynthesis of hyaluronan, another crucial component of the vocal fold lamina propria In line with this result, hyaluronan levels were significantly increased because of cigarette smoke exposure. Long term treatment of 4 days did not lead to significant changes.The current findings corroborate previous studies but also reveal new insights in possible disease mechanisms of Reinke's edema. We postulate that changes in the composition of the vocal folds' extracellular matrix -reduction of collagen fibrils, increase of hyaluronan- may lead to the clinical findings. This might ease the identification of better, disease-specific treatment options.