The role of stroboscopy in the management of a patient with a unilateral vocal fold paralysis

Guidelines for the Management of Unilateral Vocal Fold Paralysis From the Korean Society of Laryngology, Phoniatrics and Logopedics

The Korean Society of Laryngology, Phoniatrics and Logopedics appointed a task force to establish clinical practice guidelines for the management of unilateral vocal fold paralysis (UVFP). These guidelines cover a comprehensive range of management-related factors, including the diagnosis and treatment of UVFP, and provide in-depth information based on current, up-to-date knowledge. Detailed evidence profiles are provided for each recommendation. The CORE databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers, using a predefined search strategy. When insufficient evidence existed, expert opinions and Delphi questionnaires were used to fill the evidence gap. The committee developed 16 evidence-based recommendations in six categories: initial evaluation (R1–4), spontaneous recovery (R5), medical treatment (R6), surgical treatment (R7–14), voice therapy (R15), and aspiration prevention (R16). The goal of these guidelines is to assist general otolaryngologists and speech-language pathologists who are primarily responsible for treating patients with UVFP. These guidelines are also intended to facilitate understanding of the condition among other health-care providers, including primary care physicians, nurses, and policy-makers.

Quality of Voice and Prognostic Markers for the Recovery of Vocal Fold Paralysis After Thyroid Surgery

Objectives:

This study is set to analyze clinicopathological factors predicting the recovery of unilateral vocal fold paralysis (UVP) in patients after thyroid gland surgery. The quality of voice was additionally assessed in these patients.

Methods:

The charts and videolaryngostroboscopy (VLS) examinations of 84 consecutive patients with a complete UVP after surgery of the thyroid gland were retrospectively reviewed. Patients were divided into 2 groups: patients who fully recovered from vocal fold paralysis and those who failed to recover after a follow-up of 12 months. The quality of voice was analyzed among other things by determining the Voice Handicap Index (VHI).

Results:

The UVP fully recovered in 52 of 84 (61.9%) patients. Positive mucosal waves (pMWs) on the paralyzed side, a minimal glottic gap <3 mm seen at the first postoperative VLS, age ≤50 years, and surgery duration ≤120 minutes were associated factors for a complete recovery of nerve function. The voice parameters improved independently from recovery of the paralysis in 90% of the patients.

Conclusions:

For patients with a poor prognosis of a UVP, early intervention may be beneficial. Thus, predicting factors for a full recovery of vocal fold motion would be a valuable tool. In our cohort, about 60% of recoveries could have been predicted using the above-mentioned parameters. Good quality of voice was independently reached in 90% of the cases.

Prognostic Relevance of Mucosal Waves in Patients With Unilateral Vocal Fold Paralysis

OBJECTIVES

To analyze the prognostic relevance of mucosal waves (MWs) for recovery of unilateral vocal fold paralysis (UVP).

METHODS

The charts and stroboscopic examinations of 100 consecutive patients with a complete UVP were reviewed retrospectively. All had a minimal (estimated <3 mm) mucosal gap on stroboscopy. A positive or negative MW on the paralyzed vocal fold was associated with complete recovery to full adduction and abduction. All patients were followed for at least 12 months.

RESULTS

Causes of the paralysis were iatrogenic/traumatic (n = 82), malignancy associated (n = 10), and idiopathic (n = 8). In patients with positive MW at diagnosis (n = 80), the chance of recovery of unilateral vocal fold paralysis was 91.25%, whereas the chance of recovery with a negative mucosal wave (n = 20) was only 10%.

CONCLUSION

Positive MWs in stroboscopy are a predictor for recovery of (iatrogenic/traumatic) unilateral vocal fold paralysis and should be used in routine diagnostic assessment.

Improvement of vocal pathologies diagnosis using high-speed videolaryngoscopy

Introduction The study of the dynamic properties of vocal fold vibration is important for understanding the vocal production mechanism and the impact of organic and functional changes. The advent of high-speed videolaryngoscopy (HSV) has provided the possibility of seeing the real cycle of vocal fold vibration in detail through high sampling rate of successive frames and adequate spatial resolution.

Objective To describe the technique, advantages, and limitations of using HSV and digital videokymography in the diagnosis of vocal pathologies.

Methods We used HSV and digital videokymography to evaluate one normophonic individual and four patients with vocal fold pathologies (nodules, unilateral paralysis of the left vocal fold, intracordal cyst, and adductor spasmodic dysphonia). The vocal fold vibration parameters (glottic closure, vibrational symmetry, periodicity, mucosal wave, amplitude, and glottal cycle phases) were assessed.

Results Differences in the vocal vibration parameters were observed and correlated with the pathophysiology.

Conclusion HSV is the latest diagnostic tool in visual examination of vocal behavior and has considerable potential to refine our knowledge regarding the vocal fold vibration and voice production, as well as regarding the impact of pathologic conditions have on the mechanism of phonation.

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.

Speech-language cooperation protocol for the fiberoptic laryngoscopy evaluation of larynx mobility

BACKGROUND

Voice protocol.

AIM

To propose a protocol for the fiberoptic laryngoscopy evaluation of larynx mobility in thyroid illnesses (PAN), with the intention of having an objective, precise and consensual instrument for this assessment.

METHOD

The first version of the protocol was elaborated based on data found in the literature; the protocol was judged twice, using the triangulation method; a pilot version was presented and applied in 11 patients; it was then judged again by doctors and speech-language pathologists; based on the analysis of the judges and after the application of the pilot version, the final version of the PAN was proposed.

RESULTS

The final protocol was composed by two parts. The first part, considered a standard procedure, is composed by 4 essential items that necessarily should be evaluated: normal inspiration; forced inspiration; vowel /é/ isolated and sustained; and sharp vowel /i/, isolated and sustained. The second part, considered a speech-language complementation, is composed by items that should be understood as being important for speech-language pathologists as they are informative or predictive of the effectiveness of therapy: vowel /é/ sustained and weak; vowel /é/ sustained and sharp; vowel /é/ sustained and deep; vowel /é/ short with abrupt vocal onset.

CONCLUSIONS

The PAN, in its final version, contributes for the systematization of the assessment procedures based on evidence and on the agreement of professionals. The PAN results in the description of items to be obtained during medical and speech-language assessment during the fiberoptic laryngoscopy evaluation of larynx mobility in thyroid illnesses.

Voice Change Following Thyroid and Parathyroid Surgery

Voice complications following thyroid and parathyroid procedures have long been recognized in the literature. However, there is little clear data on the nature, severity, and duration of any changes. No single previous study has comprehensively addressed the multiple issues involved. Most studies have been retrospective, preventing control over extraneous variables, or are small prospective studies using limited assessment measures. Emphasis has been on damage (paralysis) to the recurrent laryngeal nerve (RLN). The effects of surgery on the more subtle (but equally important) aspects of voice disorders have received little attention. This prospective study of 67 participants used multidimensional voice outcomes measures to assess changes in voice following thyroid and parathyroid surgery. Strict exclusion criteria minimized the effects of extraneous variables. Participants were assessed preoperatively to establish a baseline and at least twice more postoperatively. Generally speaking, the patient vocal performance and expert perceptual rating data suggest an incidence of 0% for all operation types. Mild changes at the early postoperative stages had settled in all cases by the 3-month postoperative assessment. Videostroboscopic evaluation revealed an interesting picture of six patients who appeared to have improved vocal function postsurgery, 15 patients who showed signs of neurological damage at their first postoperative examination, and only five "permanent" RLN paralyses at 12 months postsurgery. The potential for improvement in voice quality postsurgery has not previously been reported in the literature as far as we are aware. Symptoms consistent with RLN and superior laryngeal nerve palsy were present both pre- and postoperatively. Apparent nerve damage did not necessarily result in dysphonia. The potential for undiagnosed nerve damage preoperatively has rarely been reported in the literature. These results may have medico-legal implications, in addition to influencing surgical risk management and informed patient consent.

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

Vocal fold augmentation by injection laryngoplasty is a simple and fast procedure. The aim of this prospective study was to assess the glottal closure and the travelling mucosal wave by videostroboscopic images after autologous fascia augmentation in unilateral vocal fold paralysis (UVFP) with a special reference to objective analysis of voice. A total of 14 UVFP patients with poor voice and open glottal gap were assessed by videostroboscopy, blinded perceptual evaluation of running speech and acoustical analysis of sustained vowel. Data were collected before the procedure and at a supplementary evaluation 5-32 months (mean: 13 months) after injection of autologous fascia deep into the paralysed vocal fold. Mean age was 59 years; there were eight women and six men. Frame-by-frame video analysis revealed that before the operation 10 out of 12 had large glottal gaps without any contact between vocal folds on phonation. After the procedure seven gaps were completely closed, four partly, and two had no mucosal contact in stroboscopic examination. Maximum gap between vocal folds decreased from 7.21 units to 1.65 units (paired t-test P<0.001). Mucosal wave amplitude symmetry and phase synchrony were present in most subjects with partial closure and phase synchrony in every patient with a proper glottic closure. A panel of listeners rated voice to be significantly better ( P<0.01) ) after the procedure, and the improvement in acoustical parameters was also statistically significant ( P<0.01). There was a good correlation between objective voice analysis and videostroboscopy. Residual glottal gap was the major reason for less than optimal postoperative voice. No signs of hampered mucosal wave were noticed. Videostroboscopy and objective voice analysis suggest that augmentation by autologous fascia does not induce scar or fibrous tissue in the subepithelial space. Slight over-correction should be attempted initially in order to accomplish sufficient augmentation. This might enhance complete glottic closure and improve the outcome.

Evidence-based treatment of paralytic dysphonia: making sense of outcomes and efficacy data

The criteria used to determine the success or failure of a given treatment for vocal fold paralysis are fundamental components of routine clinical practice and treatment outcomes research for the surgeon and voice therapist. The purpose of this article is to offer a guide to the critical interpretation of available measures of out-come and efficacy for this patient population. Such data form the basis for the practice of evidence-based medicine and voice therapy,essential if the standard of care is to evolve to the benefit of the patient. A better understanding of the potentials and limitations of each measure is important for treatment planning and patient counseling and, ultimately, for the conception of future well-designed clinical research. The complex issues regarding outcomes measurement are addressed here within the context of current treatment literature on vocal fold paralysis. Particular emphasis is placed on realistic data gathering within clinical practice.

[Laryngeal immobility after thyroidectomy]

One of the most common complications of surgery of the thyroid gland is vocal folds immobility. New advances in its management have been achieved over the last few years. Laryngeal electromyography, stroboscopy, and computerized analysis of the voice help guide diagnosis, allowing differentiation between recurrent nerve paralysis and glottis traumatism due to intubation, and further follow-up of recovery with relevant therapeutic decisions. In case of unilateral vocal fold paralysis, intrafold silicone or injection of autologous fat is more and more routinely used to obtain vocal rehabilitation. In case of bilateral vocal fold paralysis, to avoid tracheotomy, partial posterior cordectomy using laser surgery restores sufficient laryngeal airflow, with minimal vocal sequelae. Early management of these complications by teams of specialists should allow appropriate and less invasive surgery.

Permanent iatrogenic vocal cord paralysis after I-131 therapy: a case report and literature review

A patient who underwent I-131 therapy for a solitary toxic thyroid nodule subsequently experienced vocal cord paralysis, a rare complication. The patient was examined because of hoarseness 1 week after treatment. Indirect laryngoscopy at the time confirmed right vocal cord paralysis. When the examination was repeated in 6 months, no improvement was noted; vocal cord paralysis was then declared permanent. Surprisingly, 11 months after the onset of symptoms, the patient observed improvement in her voice. At 14 months, she experienced complete vocal recovery. However, a computed tomography performed after this showed that her right vocal cord paralysis was unresolved. The apparent complete recovery of her voice is believed to be a result of adaptive compensatory mechanisms. Patients who recover from hoarseness after injury to the recurrent laryngeal nerve should have cord function documented by indirect laryngoscopy or other means before the physician performs a procedure that could harm the contralateral nerve, because damage to this nerve could result in devastating consequences.

Etiology, pathophysiology, treatment choices, and voice results for unilateral adductor vocal fold paralysis: a 3-year retrospective

Unilateral vocal fold paralysis is now considered a common disorder seen in the practice of otolaryngology and voice pathology. Concern first is for the accurate diagnosis of the associated etiology in an efficient and thorough fashion. When etiology has been determined the focus of treatment becomes the management of the presenting symptoms, which typically include dysphonia and dysphagia. A retrospective study was conducted reviewing the records of 117 patients with unilateral adductor vocal fold paralysis who presented to a large otolaryngology practice and clinical voice lab from 1995 to 1998. Demographic data reveal most patients to range in age from 16 to 91 with a dominant clustering for ages 50 to 70. Gender distribution reveals males slightly exceed females in this sample. Data regarding etiology type are collected in great detail, revealing that disease and surgery involving the chest contribute the greatest to the overall number in this study and that anterior approach to cervical spine surgery contributes as much as thyroid surgery. General outcomes of the patients are reviewed. A small group (n = 25) of patients who had pretreatment and posttreatment data available revealed statistically significant differences between voice outcomes for patients who were treated with medialization and for those treated with therapy. Patients receiving therapy had less severe symptoms pretreatment, while greater gains pretreatment to posttreatment were shown for those who had surgical medialization.