Voice Surgery

[Efficacy of Novafon Local Vibration Voice Therapy and Water Resistance Therapy: a meta-analysis]

BACKGROUND

Treatment approaches for voice therapy are diverse and two treatment approaches in voice therapy with assistive devices will be evaluated and compared for efficacy. Evaluations of the treatment effects of different approaches are important for clinical consultation and evidence-based practice.

AIM

To evaluate the efficacy of Novafon Local Vibration Voice Therapy (NLVVT) and Water Resistance Therapy (WRT) using Voice Handicap Index (VHI).

DESIGN

Systematic literature search and meta-analysis with random effects model.

DATA SOURCES

The analysis of two databases (MEDLINE and CENTRAL) and a manual search from inception to September 19th 2021.

STUDY SELECTION

Any clinical trial with case series in a pre-post design written in English or German that tested the efficacy of NLVVT or WRT using VHI (functional [F], physical [P], and emotional [E] aspects, and total score [T]) in adult voice patients with an organic or functional voice disorder was considered.

RESULTS

Five eligible studies were identified (NLVVT n= 22; WRT n= 42). Both treatment approaches showed highly significant improvement in all aspects of the VHI (p-values< 0.01). In direct comparison, NLVVT achieved significantly higher improvements in VHI-T, VHI-F and VHI-E than WRT (p-values< 0.01). Comparable improvement was received in VHI-P (p= 0.28).

CONCLUSION

NLVVT and WRT are effective treatments for voice disorders related to the subjective evaluation of a voice disorder. In direct comparison, NLVVT achieved higher improvements than WRT in most VHI aspects.

The maximum phonation time as marker for voice treatment efficacy: A network meta-analysis

PURPOSE

There is a diversity in treatment approaches for voice therapy in which aerodynamic treatment effects between the approaches are lacking. The evidence of voice treatments on the maximum phonation time (MPT) was quantified using the statistical approach of a network meta-analysis (NMA).

DATA SOURCES

Three databases and manual search from inception to November 2021 were evaluated.

STUDY SELECTION

Studies were considered which were reports of randomised controlled/clinical trials (RCT) evaluating the efficacy of a specific voice therapy treatment using MPT as an outcome measure in adult participants with voice disorders. Studies were excluded if participants had been diagnosed with neurological-motor-speech disorders or who were vocally healthy. Furthermore, no medical, pharmacological, or technical instrumental treatments were used.

DATA EXTRACTION AND SYNTHESIS

Preferred Reporting Items for systematic reviews and meta-analyses extension statement guidelines were followed. Two reviewers independently screened citations, extracted data, and assessed risk of bias using PEDro scale. Random effects model was used for meta-analysis.

RESULTS

We identified finally 12 RCT studies (treatment groups n = 285, and control group without an intervention n = 62). Eight interventions were evaluated. The only effective intervention with a significant effect was vocal function exercises (VFE) (mean pre-post difference 6.16 s, 95% confidence interval, 1.18-11.13 s).

CONCLUSIONS AND RELEVANCE

VFE effectively improved MPT from pre- to post-treatment in comparison with other voice interventions which were identified in the present NMA. Further high-quality intervention studies with large samples sizes, multidimensional measures, and homogeneous groups of dysphonia are needed to support evidence-based practice in laryngology.

Mucosal Bridge Reconstruction: A Novel Approach for the Vocal Fold Mucosal Bridge

INTRODUCTION

Mucosal Bridges (MBs) are defined as benign connective tissue abnormalities of unclear etiology that extend over the free surface of the vocal fold, are attached to the front and back of the vocal fold but are not attached to its free surface, and are histologically covered by stratified squamous epithelium. In order to overcome these drawbacks, we aimed to retrospectively evaluate and present the preoperative and postoperative results of patients with MB, who were applied the method we call "Mucosal Bridge Reconstruction" (MBR), which we apply as suturing rather than resection of the MB.

METHODS

Between January 2016 and February 2020, 5 patients who applied to the voice clinic due to dysphonia and were diagnosed with MB via laryngostroboscopic examination and direct laryngoscopy under general anesthesia were included in the study. Dr Speech software was used for acoustic analysis; mean fundamental frequency (fo), jitter %, shimmer %, and noise to harmonic ratio (NHR) were objectively measured and recorded. Voice Handicap Index-10 (VHI-10) was used for positive self-reporting of the severity of vocal symptoms. GRBAS scale (G: Grade, R: Roughness, B: Breathiness, A: Asthenia, and S: Strain) was also used (by the same clinician) for clinic subjective evaluation.

RESULTS

Patient age ranged from 33 to 55 years and mean patient age was 42 years. Mean duration of symptoms was 22 months (range 16-30). Mean postoperative follow-up time was 14 months (range 6-24). Unilateral MB was observed in all patients (2 left, 3 right). There was a significant improvement in objective and subjective assessment methods in all our patients after surgery.

CONCLUSIONS

According to the results of our few patients, MBR offers a physiological and anatomical approach to the treatment of patients with MB. The outcomes of delicate microlaryngeal surgery are promising.

The effectiveness of voice therapy on voice-related handicap: A network meta-analysis

BACKGROUND

Treatment approaches for voice therapy are diverse, yet their differential effects are not well understood. Evaluations of treatment effects across approaches are important for clinical guidance and evidence-based practice.

OBJECTIVE OF REVIEW

To quantify the evidence of treatment effectiveness on the outcome measure Voice Handicap Index with the 30-items (VHI-30) from existing randomised controlled/clinical trials (RCT) of voice therapy using the statistical approach of a network meta-analysis (NMA) with a random effects model.

TYPE OF REVIEW

Meta-analysis.

SEARCH STRATEGY

We searched in MEDLINE (PubMed, 1950 to 2019), Embase (1974 to 2019) and Science Citation Index (1994 to 2019) using five key terms. The inclusion criteria were reports of randomised controlled/clinical trials (RCTs) published in English or German which evaluated the effectiveness of a specific voice therapy treatment using VHI-30 as an outcome measure in adult participants with non-organic or organic voice disorders. Studies were excluded if participants had been diagnosed with neurological motor speech disorders or who were vocally healthy. Furthermore, no medical, pharmacological or instrumental (eg voice amplification) treatments were considered.

EVALUATION METHOD

The primary outcome variable was VHI-30 with a score from 0 to 120. The pre-post treatment change in VHI-30 scores was an average score of 13 points related to various VHI-30 test-retest results.

RESULTS

We retrieved 464 publications (ie with duplicates) and included 13 RCTs, which evaluated nine interventions, in the final analysis. The most effective intervention with a significant and clinically relevant effect was Stretch-and-Flow Phonation (SFP) (mean pre-post difference -28.37, 95% confidence interval [CI], -43.05 to-13.68). Resonant Voice (RV), the Comprehensive Voice Rehabilitation Program (CVRP) and Vocal Function Exercises (VFE) also demonstrated significant improvements.

CONCLUSIONS

Of the nine voice interventions identified with the present NMA, SFP, RVT, CVRP, and VFE effectively improved VHI-30 scores from pre- to post-treatment. SFP proved to be the most significant and clinically relevant treatment. Further contributions of high-quality intervention studies are needed to support evidence-based practice in vocology.

[The modern possibilities for the treatment of the patients presenting with benign and tumour-like diseases of the larynx]

Rehabilitation of the patients presenting with benign and tumour-like diseases of the larynx (BLT) is currently a serious challenge for modern otorhinolaryngology in view of the high prevalence of this pathology. Dysphonia is a leading clinical symptom of the diseases that considerably deteriorates the quality of life of the patients. Certain benign conditions of the larynx exhibit a tendency toward malignization. The treatment of the patients presenting with benign and tumour-like diseases of the larynx requires a combined approach including the surgical, therapeutic, and phonopedic modalities for the rehabilitation of the vocal function. This article presents a review of the literature on the modern high-energy techniques for the treatment of the patients presenting with benign and tumour-like diseases of the larynx, The advantages and disadvantages of each method are discussed.

Indications for Direct Laryngoscopic Examination of Vocal Cord Function Prior to Anterior Cervical Surgery

Recurrent laryngeal nerve palsy (RLNP) is among the most common complications in both thyroid surgeries and anterior approaches to the cervical spine, having both a diverse etiology and presentation. Most bilateral paresis, with subsequent devastating impact on patients, are due to failure to recognize unilateral recurrent laryngeal nerve paralysis and, although rare, are entirely preventable with appropriate history and screening. Recurrent laryngeal nerve palsy has been shown to present asymptomatically in as high as 32% of cases, which yields limitations on exclusively screening with physical examination. Based on the available literature, diagnosis of unilateral RLNP is the critical factor in preventing the occurrence of bilateral RLNP as the surgeon may elect to operate on the injured side to prevent bilateral paresis. Analysis of incidence rates shows postoperative development of unilateral RLNP is 13.1 (95% confidence interval [CI]: 6.1-28.1) and 13.90 (95% CI: 6.6-29.3) times more likely in anterior spine and thyroid surgery, respectively, in comparison with intubation. Currently, there is no consensus on when to order a preoperative laryngoscopic examination prior to anterior cervical spine surgery. The importance of patient history should be emphasized, as it is the basis for indications of preoperative laryngoscopy. Efforts to minimize postoperative complications must be made, especially when considering the rising rate of cervical fusion. This study presents a systematic review of the literature defining key causes of RLNP, with a probability-based protocol to indicate direct laryngoscopy prior to anterior cervical surgery as a screening tool in the prevention of bilateral RLNP.

Diagnostic and therapeutic pitfalls in benign vocal fold diseases

More than half of patients presenting with hoarseness show benign vocal fold changes. The clinician should be familiar with the anatomy, physiology and functional aspects of voice disorders and also the modern diagnostic and therapeutic possibilities in order to ensure an optimal and patient specific management. This review article focuses on the diagnostic and therapeutic limitations and difficulties of treatment of benign vocal fold tumors, the management and prevention of scarred vocal folds and the issue of unilateral vocal fold paresis.

Vocal fold scars: current concepts and future directions. Consensus report of the Phonosurgery Committee of the European Laryngological Society

Scarring of the vocal folds leads to a deterioration of the highly complex micro-structure with consecutively impaired vibratory pattern and glottic insufficiency. The resulting dysphonia is predominantly characterized by a reduced vocal capacity. Despite the considerable progress in understanding of the underlying pathophysiology, the treatment of scarred vocal folds is still an unresolved chapter in laryngology and phonosurgery. Essential for a successful treatment is an individual, multi-dimensional concept that comprises the whole armamentarium of surgical and non-surgical (i.p. voice therapy) modalities. An ideal approach would be to soften the scar, because the reduced pliability and consequently the increased vibratory rigidity impede the easiness of vibration. The chosen phonosurgical method is determined by the main clinical feature: Medialization techniques for the treatment of glottic gap, or epithelium freeing techniques for improvement of vibration characteristics often combined with injection augmentation or implantation. In severe cases, buccal mucosa grafting can be an option. New developments, include treatment with anxiolytic lasers, laser technology with ultrafine excision/ablation properties avoiding coagulation (Picosecond infrared laser, PIRL), or techniques of tissue engineering. However, despite the promising results by in vitro experiments, animal studies and first clinical trials, the step into clinical routine application has yet to be taken.

Sulcus mucosal slicing technique

PURPOSE OF REVIEW

To present the accurate surgical indication for the slicing mucosal technique, the case selection, surgical aspects, rehabilitation concerns, and the characteristics of immediate and long-term outcomes.

RECENT FINDINGS

The literature is still scarce; few cases are submitted to the slicing mucosa technique due to its specific indication; an alternative procedure was designed for cases where mucosal movement is strongly reduced, the inner section of the vocal ligament or submucosal scar tissue, which can eventually be associated with fat inclusion. Some selected cases may require thyroplasty type III to optimize functional results.

SUMMARY

Slicing technique is an aggressive powerful resource for the surgical treatment of severe cases of sulcus striae major, in which mucosal wave is absent and glottic chink is moderate to severe; voice is intensely deviated immediately postoperation; vocal rehabilitation is mandatory and an intensive regimen is usually required for the first 2 months; final results can mostly be achieved up to 6 months.

Radiophonosurgery of vocal fold nodules

PURPOSE OF REVIEW

To describe the current support in the literature for radiophonosurgery in cases of vocal fold nodules.

RECENT FINDINGS

Radiophonosurgery is a recent innovation in the field of laryngeal surgery. It is emerging as a reliable and practical method for treating benign superficial vocal fold lesions that is increasingly becoming popular. It induces an excellent subjective and objective improvement in voice parameters. Histologically, it produces unremarkable lateral thermal damage and char penetration, which is quite crucial in a functional surgery such as in phonosurgery. Well designed probes are still lacking in the market.

SUMMARY

Radiophonosurgery provides a new approach for patients with vocal fold nodules. It combines the advantages of both cold knife and laser phonosurgery and is easy, well tolerated, precise and effective with excellent tactile and hemostatic properties.

Conservative treatment vs phonosurgery

In Phoniatric Dpt. everyday practice we try to keep specific multidisciplinary approach to the communication disorders, that includes an expert team using modern technology. Over the last six years we have treated 110 singers (3% of all new cases) and the results of their diagnostic and therapeutic management are presented here. There were 67 women and 43 men, 41 were smokers and 69 nonsmokers. The singing genres included 24 pop, 41 folk, 8 ethnic, 29 choral and 8 opera singers. The therapy success was compared with the demographic parameters, level of education and music genres across the subjects. A precise history, clinical examination, endovideolaryngostroboscopy and multidimensional computer analysis of voice and speech was carried out by two phoniatricians, two logopeds, two nurses and one clinical psychologist. Additional consultations were carried out by audiologists, allergists, endocrinologists, chest physicians, gastroenterologists and neurologists where necessary. We suggest that the gold standard is conservative therapy, with phonosurgery if conservative measures fail. We also suggest that an annual systematic examination is optimal in preventing disease in professional singers.

Microendoscopy of Reinke's Space

Objectives:

Contemporary surgical treatment of the superficial layer of the lamina propria or Reinke's space is most commonly performed through an incision in the overlying vocal fold epithelium. This approach may disrupt normal tissue, induce scarring, and allow extrusion of implanted materials. Previously reported external approaches to Reinke's space required either a laryngofissure or a “minithyrotomy” for access. These surgical approaches were performed without direct imaging of Reinke's space. Instruments placed below the vocal fold epithelium via this external approach were visualized through the translucent vocal fold epithelium. We designed this study to identify the feasibility of limited-access surgery of the lamina propria using microendoscopes placed into Reinke's space through an external approach.

Methods:

A cadaveric human larynx was dissected, and microendoscopes were directly advanced into Reinke's space through a subepithelial puncture of the cricothyroid membrane, as well as lateral fenestration through the thyroid cartilage.

Results:

Photodocumentation of the undersurface of vocal fold epithelium, the opposing surface of the vocal ligament, and the intervening Reinke's space was successfully accomplished.

Conclusions:

Advances in both microendoscopes and accompanying instrumentation permit access to the superficial layer of the lamina propria without disrupting the overlying epithelium. This approach to microendoscopy of Reinke's space may allow for more effective surgical treatment of cysts, chronic edema, vascular abnormalities, atrophy, scarring, and sulcus vocalis.