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Valley ZA, Karp A, Garber D. Safety and Adverse Events of Medialization Thyroplasty: A Systematic Review. Laryngoscope 2024; 134:1994-2004. [PMID: 37916789 DOI: 10.1002/lary.31141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 11/03/2023]
Abstract
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.
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Affiliation(s)
- Zachary A Valley
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Avrohom Karp
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - David Garber
- Department of Otolaryngology-Head and Neck Surgery, Westchester Medical Center, Valhalla, New York, USA
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2
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Huang PK, Chen CK, Yu YH, Ho GM, Hsieh LC. Long-term voice outcomes of medialization thyroplasty with adjustable implant for unilateral vocal fold paralysis. Eur Arch Otorhinolaryngol 2024; 281:1371-1378. [PMID: 38085304 DOI: 10.1007/s00405-023-08367-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/19/2023] [Indexed: 02/10/2024]
Abstract
OBJECTIVES Medialization thyroplasty (MT) using various implants has been employed as a corrective procedure for unilateral vocal fold paralysis (UVFP). A newly developed APrevent® vocal implant system (VOIS) offers an innovative solution with a finely adjustable design. This study aimed to investigate the long-term functional voice outcomes and benefits of postoperative adjustments in patients receiving MT using the VOIS-implant. METHODS This is a prospective case series study at single tertiary medical center. Fourteen adult patients diagnosed with UVFP received MT with the VOIS implant and were followed up for more than 1 year. Implant adjustment procedure by injecting 0.9% physiological saline solution was performed both during and after the surgery to optimize glottal closure and voice quality. Objective voice outcomes and acoustic parameters were assessed preoperatively and postoperatively at various timepoints. RESULTS Thirteen patients (93%) received intraoperative balloon adjustment, ranging from 0.05to 0.12 ml. Four patients underwent adjustments postoperatively and exhibited a positive trend towards immediately improving acoustic voice quality. Our long-term results demonstrated a notable improvement after the surgery in voice quality, with significant decreases in VHI-30 and improvements in perceptual parameters of GRBAS scale, acoustic measures such as jitter and signal-to-noise ratio (p < 0.001) and cepstral peak prominence smoothed in sustained vowel and short sentences. The voice outcomes remained stable more than 1 year follow-up. CONCLUSIONS Overall, MT with VOIS implantation provides a favorable long-term outcomes and stability in voice quality for patients with UVFP and also an effective tool for postoperative adjustment without major revision surgeries.
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Affiliation(s)
- Po-Kai Huang
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei City, 10449, Taiwan
| | - Chin-Kuo Chen
- Department of Otolaryngology-Head and Neck Surgery, Communication Enhancement Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Hsuan Yu
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei City, 10449, Taiwan
- Department of Audiology and Speech Language Pathology, Mackay Medical College, New Taipei, Taiwan
| | - Guan-Min Ho
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei City, 10449, Taiwan.
- Yomin ENT and Pediatric Clinic, Taipei, Taiwan.
- APrevent® Medical, Taipei, Taiwan.
| | - Li-Chun Hsieh
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd., Taipei City, 10449, Taiwan.
- Department of Audiology and Speech Language Pathology, Mackay Medical College, New Taipei, Taiwan.
- Department of Medicine, Mackay Medical College, New Taipei, Taiwan.
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Chen AWG, Chen CH, Lin TM, Chang ACH, Tsai TP, Chang SY. Office-Based Structural Autologous Fat Injection Laryngoplasty for Unilateral Vocal Fold Paralysis. J Clin Med 2022; 11:jcm11164806. [PMID: 36013042 PMCID: PMC9410197 DOI: 10.3390/jcm11164806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/11/2022] [Accepted: 08/13/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Andy Wei-Ge Chen
- Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Chih-Hua Chen
- Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua 500, Taiwan
| | - Tsai-Ming Lin
- Charming Institute of Aesthetic and Regenerative Surgery, Kaohsiung 807, Taiwan
- Department of Plastic Surgery, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Angela Chih-Hui Chang
- Voice Center, Department of Otolaryngology, Cheng Hsin General Hospital, Taipei 114, Taiwan
| | - Tzu-Pei Tsai
- Department of Speech, Language and Hearing Sciences, Indiana University Bloomington, Bloomington, IN 47408, USA
| | - Shyue-Yih Chang
- Voice Center, Department of Otolaryngology, Cheng Hsin General Hospital, Taipei 114, Taiwan
- Correspondence: ; Tel.: +886-2-28264400
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Müller A. Active and Passive Bioimplants for Vocal Fold Paralysis. Laryngorhinootologie 2022; 101:S144-S159. [PMID: 35605617 DOI: 10.1055/a-1708-2881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Lee IY, Chang SF, Wu CY, Lin YS, Su HC, Tsai YT, Tsai MS, Chang GH, Yang MY, Yang YH, Yang PR, Hsu CM. Clinical and Cellular Evidence of Glycyrrhiza glabra and Platycodon grandiflorus for Vocal Fold Nodules Complementary Treatment. Int J Med Sci 2022; 19:813-820. [PMID: 35693740 PMCID: PMC9149633 DOI: 10.7150/ijms.68118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 04/18/2022] [Indexed: 11/08/2022] Open
Abstract
Vocal fold nodules (VFNs) are the most frequent cause of hoarseness. The management comprised medical, surgical and physical therapy but the effectiveness is not always satisfactory. In this study, we try to figure out an alternative treatment from our clinical experience summary. We retrospectively reviewed VFNs patients who received traditional Chinese medicine (TCM) treatments from July 2018 to August 2020 and traced their Chinese Voice Handicap Index-10 (VHI-C10) and multidimensional voice program (MDVP) analysis results. For further evaluation, we conducted an inflammatory response of porcine vocal fold epithelial (PVFE) cells with 50 ng/mL TNF-alpha. The inflamed PVFE cells were separately cultured in the aqueous extract of Glycyrrhiza glabra (G. glabra) and Platycodon grandifloras (P. grandifloras). In these VFNs patients (n = 22), the average VHI-C10 score decreased from 17.6 to 6.6 (p < 0.001). MDVP analysis revealed improvements in jitter, shimmer, noise-harmonic ratio, and GRBAS scoring system. Of the TCM prescription patterns, G. glabra and P. grandiflorus were used most frequently. In the MTT assay of PVFE cells, no adverse effects of our extracts were observed at doses of 1-200 µg/mL. Western blot analysis revealed downregulation of p65 and mitogen activated protein kinase pathway proteins. The results from both the clinical and in vitro aspects of this study revealed that the herbs G. glabra and P. grandiflorus may offer beneficial outcomes as alternative treatments for VFNs after precise diagnosis.
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Affiliation(s)
- I-Yun Lee
- Department of Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan.,School of Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shun-Fu Chang
- Department of Medical Research and Development, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan
| | - Chin-Yuan Wu
- Department of Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan.,School of Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yu-Shi Lin
- Department of Pharmacy, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Hui-Chen Su
- Department of Neurology, National Cheng-Kung University Hospital, Tainan, Taiwan
| | - Yao-Te Tsai
- Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan
| | - Ming-Shao Tsai
- Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan
| | - Geng-He Chang
- Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan
| | - Ming-Yu Yang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan.,Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Yao-Hsu Yang
- Department of Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan.,School of Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Pei-Rung Yang
- Department of Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan.,School of Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Cheng-Ming Hsu
- Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 61363, Taiwan.,School of Medicine, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
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Hsieh LC, Chen CK, Chang CW, Leu YS, Ho GM. Preliminary Clinical Outcomes of VOIS-Implant in Patients With Unilateral Vocal Fold Paralysis. Laryngoscope 2021; 132:1622-1629. [PMID: 34817072 DOI: 10.1002/lary.29958] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/07/2021] [Accepted: 11/15/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Evaluation of the clinical outcomes after 6 months of treatment with a novel adjustable implant, the APrevent® Vocal-Implant-System (VOIS), in conjunction with medialization thyroplasty (MT) in patients with unilateral vocal fold paralysis. STUDY DESIGN Prospective case series study at single tertiary referral center. METHODS Preoperative and 1 week, 7 weeks, and 6 months postoperative glottal efficiency (maximum phonation time [MPT]), voice quality (including GRBAS-scores and acoustic parameters) and self-perceived voice-related handicap (voice handicap index [VHI-30]) were measured and analyzed, whereas type of vocal fold closure was evaluated and determined by flexible videolaryngoscopy based on Södersten and Lindestad classification (Wilcoxon signed-rank test). RESULTS Thirteen patients underwent MT with VOIS under local anesthesia. Six months after surgery, the VHI-30 and MPT had improved from a preoperative mean of 75.0 ± 22.9 and 2.7 ± 2.1 s to a postoperative mean of 20.6 ± 19.7 and 6.3 ± 4.0 s, respectively. The mean GRBAS score improved from preoperative scores of Gpreop = 2.7, Rpreop = 2.6, Bpreop = 2.6, Apreop = 2.2, and Spreop = 2.0 to Gpostop = 0.3, Rpostop = 0.3, Bpostop = 0.2, Apostop = 0.2, and Spostop = 0.3 at 6 months postoperatively. Improved glottal closure was achieved in all patients (n = 13). Five patients received postoperative adjustment for the optimization of voice quality and glottal closure. No intra- or postoperative complications were observed. Significant improvements in acoustic parameters, including percentage jitter, percentage shimmer, and signal-to-noise ratio, were also observed after MT. All results were statistically significant (P < .05, Cohen's d > .8). CONCLUSIONS APrevent® VOIS-Implantation is a safe procedure with good voice outcomes. Postoperative adjustments can be performed smoothly to optimize voice quality and glottal closure. LEVEL OF EVIDENCE III Laryngoscope, 2021.
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Affiliation(s)
- Li-Chun Hsieh
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Audiology and Speech Language Pathology, Mackay Medical College, Taipei, Taiwan
| | - Chin-Kuo Chen
- Communication Enhancement Center and Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chin-Wen Chang
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Audiology and Speech Language Pathology, Mackay Medical College, Taipei, Taiwan
| | - Yi-Shing Leu
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Taipei, Taiwan
| | - Guan-Min Ho
- Department of Otolaryngology-Head and Neck Surgery, Mackay Memorial Hospital, Taipei, Taiwan.,Yomin ENT and Pediatric Clinic, APrevent Medical, Taipei, Taiwan
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7
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Hsu CM, Tsai YT, Chang GH, Yang YH, Fang TJ, Lee YC, Liu CY, Lin MH, Wang YT, Tsai MS. Reduction in Short- and Long-term Pneumonia Rate With Laryngoplasty for Unilateral Vocal Fold Paralysis. Otolaryngol Head Neck Surg 2021; 166:343-349. [PMID: 34058910 DOI: 10.1177/01945998211015174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the association of laryngoplasty, voice therapy, and pneumonia rate in patients with unilateral vocal fold paralysis (UVFP). STUDY DESIGN Population-based retrospective cohort study. SETTING Data were collected from the LHID2000 (Longitudinal Health Insurance Database 2000), containing the information of 1 million randomly selected patients in Taiwan. METHODS In the LHID2000, we identified 439 patients having new diagnoses of UVFP from 1997 to 2013. We grouped the aforementioned patients according to UVFP treatment and probed the occurrence of pneumonia: 305 patients underwent laryngoplasty or voice therapy, and 134 patients did not undergo treatment. Follow-up procedures were executed for the enrollees until death or December 31, 2013, representing the end of the study period. We assessed the association of UVFP treatment and pneumonia by executing Cox proportional hazards regression. RESULTS The pneumonia cumulative incidence was significantly higher among enrolled patients without treatment than in those receiving treatment (P < .001). The pneumonia incidence was significantly lower in patients receiving UVFP treatment (hazard ratio, 0.49; 95% CI, 0.27-0.88; P = .018), as validated by the Cox proportional hazards model after adjustment. Patients undergoing laryngoplasty with or without voice therapy had a significantly lower incidence of pneumonia at 6 months and 1, 3, and 5 years, whereas those undergoing voice therapy alone did not. CONCLUSION Laryngoplasty was associated with a lower incidence of short- and long-term pneumonia in patients with UVFP. Physicians should encourage patients with UVFP at risk of aspiration to receive prompt evaluation as well as treatment.
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Affiliation(s)
- Cheng-Ming Hsu
- Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi.,Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan
| | - Yao-Te Tsai
- Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi.,Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan
| | - Geng-He Chang
- Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi.,Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan.,Health Information and Epidemiology Laboratory, Chiayi Chang Gung Memorial Hospital, Chiayi
| | - Yao-Hsu Yang
- Health Information and Epidemiology Laboratory, Chiayi Chang Gung Memorial Hospital, Chiayi.,School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan.,Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi
| | - Tuan-Jen Fang
- Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan.,Department of Otolaryngology-Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan
| | - Yi-Chan Lee
- Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan.,Department of Otolaryngology-Head and Neck Surgery, Keelung Chang Gung Memorial Hospital, Keelung
| | - Chia-Yen Liu
- Health Information and Epidemiology Laboratory, Chiayi Chang Gung Memorial Hospital, Chiayi
| | - Meng-Hung Lin
- Health Information and Epidemiology Laboratory, Chiayi Chang Gung Memorial Hospital, Chiayi
| | - Yun-Ting Wang
- Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi.,Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan
| | - Ming-Shao Tsai
- Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi.,Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan.,Health Information and Epidemiology Laboratory, Chiayi Chang Gung Memorial Hospital, Chiayi
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9
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Wilson A, Kimball EE, Sayce L, Luo H, Khosla SM, Rousseau B. Medialization Laryngoplasty: A Review for Speech-Language Pathologists. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2021; 64:481-490. [PMID: 33524276 PMCID: PMC8632480 DOI: 10.1044/2020_jslhr-20-00344] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/18/2020] [Accepted: 11/17/2020] [Indexed: 05/26/2023]
Abstract
Purpose The purpose of this study is to familiarize speech-language-pathologists with the current state of the science regarding medialization laryngoplasty in the treatment of voice disorders, with emphasis on current evidence-based practice, voice outcomes, and future directions for research. Method A literature review was performed in PubMed and Embase using the keywords vocal fold/cord and laryngoplasty, thyroplasty, augmentation, or laryngeal framework. Articles published between 2010 and 2020 were reviewed for data about clinical applications, technical approach, voice-related outcomes, and basic science or clinical innovations with the potential to improve patient care. A synthesis of data was performed from articles meeting the outlined search criteria. Conclusions As key members in the multidisciplinary care of voice disorders, speech-language pathologists need to be informed of current research in medialization laryngoplasty, a procedure commonly used for patients with glottic insufficiency. Advances in anesthetic technique, office-based procedures, and the development of materials with increased bio-tolerability over the past decade have led to innovations in treatment and improved patient outcomes. Recent applications of computational and bioengineering approaches have the potential to provide new directions in the refinement of currently available techniques and the improvement of patient-based treatment outcomes.
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Affiliation(s)
- Azure Wilson
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, PA
| | - Emily E. Kimball
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN
| | - Lea Sayce
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, PA
| | - Haoxiang Luo
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, TN
| | - Sid M. Khosla
- Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of Medicine, OH
- Neurosensory Disorder Center at UC Gardner Neuroscience Institute, Cincinnati, OH
| | - Bernard Rousseau
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, PA
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Chang GH, Chou FF, Tsai MS, Tsai YT, Yang MY, Huang EI, Su HC, Hsu CM. Real-world evidence and optimization of vocal dysfunction in end-stage renal disease patients with secondary hyperparathyroidism. Sci Rep 2021; 11:653. [PMID: 33436789 PMCID: PMC7804098 DOI: 10.1038/s41598-020-79810-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 12/09/2020] [Indexed: 11/09/2022] Open
Abstract
Patients with end-stage renal disease (ESRD) may demonstrate secondary hyperparathyroidism (SHPT), characterized by parathyroid hormone oversecretion in response to electrolyte imbalance (e.g., hypocalcemia and hyperphosphatemia). Moreover, this electrolyte imbalance may affect vocal cord muscle contraction and lead to voice change. Here, we explored the effects of SHPT on the voices of patients with ESRD. We used data of 147,026 patients with ESRD from the registry for catastrophic illness patients, a sub-database of Taiwan National Health Insurance Research Database. We divided these patients into 2 groups based on whether they had hyperparathyroidism (HPT) and compared vocal dysfunction (VD) incidence among them. We also prospectively included 60 ESRD patients with SHPT; 45 of them underwent parathyroidectomy. Preoperatively and postoperatively, voice analysis was used to investigate changes in vocal parameters. In the real-world database analysis, the presence of HPT significantly increased VD incidence in patients with ESRD (p = 0.003): Cox regression analysis results indicated that patients with ESRD had an approximately 1.6-fold increased VD risk (p = 0.003). In the clinical analysis, the “jitter” and “shimmer” factors improved significantly after operation, whereas the aerodynamic factors remained unchanged. In conclusion, SHPT was an independent risk factor for VD in patients with ESRD, mainly affecting their acoustic factors.
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Affiliation(s)
- Geng-He Chang
- Department of Otolaryngology - Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, No 6, Sec. West, Jiapu Rd., Puzi-City, Chiayi County, Taiwan.,Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Fong-Fu Chou
- Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ming-Shao Tsai
- Department of Otolaryngology - Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, No 6, Sec. West, Jiapu Rd., Puzi-City, Chiayi County, Taiwan.,Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yao-Te Tsai
- Department of Otolaryngology - Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, No 6, Sec. West, Jiapu Rd., Puzi-City, Chiayi County, Taiwan.,Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Yu Yang
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ethan I Huang
- Department of Otolaryngology - Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, No 6, Sec. West, Jiapu Rd., Puzi-City, Chiayi County, Taiwan
| | - Hui-Chen Su
- Department of Neurology, National Cheng-Kung University Hospital, Tainan, Taiwan
| | - Cheng-Ming Hsu
- Department of Otolaryngology - Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, No 6, Sec. West, Jiapu Rd., Puzi-City, Chiayi County, Taiwan. .,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Patient-Related Factors of Medialization Laryngoplasty with Autologous Thyroid Cartilage. Healthcare (Basel) 2020; 8:healthcare8040521. [PMID: 33266030 PMCID: PMC7711452 DOI: 10.3390/healthcare8040521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 11/18/2022] Open
Abstract
(1) Background: Medialization laryngoplasty with autologous thyroid cartilage (MLATC) is a surgical treatment for glottal closure insufficiency (GCI) resulted from unilateral vocal fold paralysis/paresis (UVFP) and vocal fold atrophy. We aimed to survey the influence of patient-related factors on the outcomes after MLATC. (2) Methods: The study enrolled 35 patients with GCI who underwent MLATC. Patient voice data were recorded before and after MLATC by using multiple acoustic parameters and subjective assessment in a computerized speech laboratory. GCI patients were characterized into subgroups based on three factors: age, ≥60 vs. <60 years; sex, men vs. women; and BMI, ≥24 vs. <24. (3) Results: When the subgroups were compared, men did not have better results after surgery than women. Patients ages < 60 years did not exhibit any significantly different outcome compared with those aged ≥ 60 years. Patients with BMI ≥ 24 did not have any significantly different outcome compared with those with BMI < 24. The subgroups of age, sex, and BMI had no significant difference in cumulative voice recovery and summation of GRBAS (G = grade, R = roughness, B = breathiness, A = asthenia, and S = strain). (4) Conclusions: MLATC is a good alternative surgery with long-term improvement in GCI patients. There is no evidence that age, sex, or BMI affect the functional outcome.
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Hsu CM, Yang MY, Fang TJ, Wu CY, Tsai YT, Chang GH, Tsai MS. Maximum and Minimum Phonatory Glottal Area before and after Treatment for Vocal Nodules. Healthcare (Basel) 2020; 8:healthcare8030326. [PMID: 32906704 PMCID: PMC7551475 DOI: 10.3390/healthcare8030326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/29/2020] [Accepted: 09/04/2020] [Indexed: 11/30/2022] Open
Abstract
Background: Vocal fold nodules (VFNs) are a challenge for otolaryngologists. Glottal area (GA) waveform analysis is an examination method used for assessing vocal fold vibration and function. However, GA in patients with VFNs has rarely been studied. This study investigated the maximum and minimum GA in VFN patients using modern waveform analysis combining ImageJ software and videostroboscopy. Methods: This study enrolled 42 patients newly diagnosed with VFN, 15 of whom received voice therapy and 27 of whom underwent surgery. Acoustic parameters and maximum phonation time (MPT) were recorded, and patients completed the Chinese Voice Handicap Index-10 (VHI-C10) before and after treatment. After videostroboscopy examination, the maximum and minimum GAs were calculated using ImageJ software. The GAs of patients with VFNs before and after surgery or voice therapy were analyzed. Results: The MPTs of the patients before and after voice therapy or surgery did not change significantly. VHI-C10 scores decreased after voice therapy but the decrease was nonsignificant (14.0 ± 8.44 vs. 9.40 ± 10.24, p = 0.222); VHI-C10 scores were significantly decreased after surgery (22.53 ± 7.17 vs. 12.75 ± 9.84, p = 0.038). Voice therapy significantly increased the maximum GA (5.58 ± 2.41 vs. 8.65 ± 3.17, p = 0.012) and nonsignificantly decreased the minimum GA (0.60 ± 0.73 vs. 0.21 ± 0.46, p = 0.098). Surgery nonsignificantly increased the maximum GA (6.34 ± 3.82 vs. 8.73 ± 5.57, p = 0.118) and significantly decreased the minimum GA (0.30 ± 0.59 vs. 0.00 ± 0.00, p = 0.036). Conclusion: This study investigated the GA of patients with VFNs who received voice therapy or surgery. The findings indicated that voice therapy significantly increased maximum GA and surgery significantly decreased minimum GA. GA analysis could be applied to evaluate the efficacy of voice therapy, and it may help physicians to develop precise treatment for VFN patients (either by optimizing voice therapy or by performing surgery directly).
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Affiliation(s)
- Cheng-Ming Hsu
- Department of Otolaryngology–Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan; (C.-M.H.); (Y.-T.T.); (G.-H.C.)
- Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Ming-Yu Yang
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan;
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Tuan-Jen Fang
- Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
- Department of Otolaryngology–Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Ching-Yuan Wu
- Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan;
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yao-Te Tsai
- Department of Otolaryngology–Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan; (C.-M.H.); (Y.-T.T.); (G.-H.C.)
| | - Geng-He Chang
- Department of Otolaryngology–Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan; (C.-M.H.); (Y.-T.T.); (G.-H.C.)
| | - Ming-Shao Tsai
- Department of Otolaryngology–Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi 613, Taiwan; (C.-M.H.); (Y.-T.T.); (G.-H.C.)
- Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Correspondence: ; Tel.: +886-53621000 (ext. 2076); Fax: +886-53623002
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Rovó L, Ambrus A, Tóbiás Z, Wootten CT, Bach Á. A Novel Endoscopic Arytenoid Medialization for Unilateral Vocal Fold Paralysis. Laryngoscope 2020; 131:E903-E910. [PMID: 32790084 DOI: 10.1002/lary.29001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/12/2020] [Accepted: 07/19/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Arytenoid adduction (AA) has been indicated for unilateral vocal fold paralysis (UVFP) patients with vertical vocal fold height mismatch and/or large posterior glottic gaps that are unable to be adequately addressed by anterior medialization techniques. Although AA offers several advantages over other methods, it is technically challenging and involves significant laryngeal manipulation of the cricoarytenoid joint. A novel, minimally invasive endoscopic arytenoid medialization technique is presented for the closure of the posterior commissure. STUDY DESIGN Prospective case series. METHODS Seventeen consecutive patients were diagnosed and treated with unilateral endoscopic arytenoid medialization (EAM) combined with injection laryngoplasty because of unilateral vocal fold paralysis. Jitter, shimmer, harmonics-to-noise ratio (HNR), maximum phonation time (MPT), fundamental frequency (F0 ), Voice Handicap Index (VHI), peak inspiratory flow (PIF), and quality of life (QoL) were evaluated preoperatively, 1 month, and 1 year after EAM. RESULTS Jitter, shimmer, HNR, and MPT significantly improved and remained stable 1 year after the intervention. F0 and PIF remained unchanged. Significant improvements in VHI and QoL demonstrated patient satisfaction with voicing and respiratory functions. CONCLUSIONS Endoscopic arytenoid medialization is a quick, minimally invasive solution for unilateral vocal fold paralysis. With simultaneous augmentation of the vocal fold, it provides a complete glottic closure along the entire vocal fold in UVFP patients. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E903-E910, 2021.
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Affiliation(s)
- László Rovó
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Szeged, Szeged, Hungary
| | - Andrea Ambrus
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Szeged, Szeged, Hungary
| | - Zoltán Tóbiás
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Szeged, Szeged, Hungary
| | - Christopher T Wootten
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, U.S.A
| | - Ádám Bach
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Szeged, Szeged, Hungary
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Tsai MS, Chang GH, Tsai YT, Hsu CM. Comments on “Cardiothoracic Patients with Unilateral Vocal Fold Paralysis: Pneumonia Rates Following Injection Laryngoplasty”. Ann Otol Rhinol Laryngol 2020; 130:223-224. [DOI: 10.1177/0003489420950377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ming-Shao Tsai
- Department of Otolaryngology—Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi
- Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan
| | - Geng-He Chang
- Department of Otolaryngology—Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan
| | - Yao-Te Tsai
- Department of Otolaryngology—Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi
| | - Cheng-Ming Hsu
- Department of Otolaryngology—Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi
- Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan
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The Utility of Strap Muscle in Complex Type I Thyroplasties. J Voice 2019; 35:493-496. [PMID: 31543359 DOI: 10.1016/j.jvoice.2019.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Type I thyroplasty is a common procedure used to improve dysphonia secondary to glottic insufficiency caused by vocal fold paralysis, paresis, or bowing. Revision often involves more complex procedures that can be complicated by mucosal violation, hemorrhage, infection, and shifted or extruded implants. Intraoperative challenges can be managed successfully using autologous strap muscle rotation flaps. OBJECTIVES Review vocal fold medialization with strap muscle as a viable option for thyroplasty, particularly operations with inadvertent mucosal disruption. METHODS All operative records of the senior author's 30-year experience were queried for modified, complex, or revision type I thyroplasties. Each of these was reviewed, and only those utilizing autologous strap muscle rotation flaps for vocal fold medialization were included. Changes in voice quality were assessed using strobovideolaryngoscopic assessment of glottic closure and Voice Handicap Index-10 (VHI-10) scores when available. RESULTS Seven patients were found to have undergone eight type I thyroplasty using autologous strap muscle flaps. Improved glottic closure was seen in all patients except one. This patient, complicated by a laryngeal fracture of unknown origin discovered at the time of surgery, had worse voice with strap muscle implantation intraoperatively; therefore, the patient's fracture was reduced, and medialization was postponed. All other patients reported improved voice quality both intra- and postoperatively. Pre- and postoperative VHI-10 scores were available for two of the seven cases with successfully implanted strap muscles. A decrease in VHI-10 was observed in both cases (mean = 11). No postoperative complications occurred in any patient. CONCLUSION Although revision thyroplasties are relatively rare, they can be challenging. The seven cases presented herein illustrate the successful and safe use of autologous strap muscle rotation flaps for complex, revision type I thyroplasty procedures. They are particularly helpful in cases requiring additional soft tissue between the thyroid cartilage and mucosa in preparation for possible future medialization after Gore-Tex or Silastic implants, and for inadvertent mucosal disruption in which using a foreign implant might pose a risk of infection. Future studies should be performed with larger populations and longer follow-up to confirm the efficacy and safety of this procedure.
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Sethia R, Ivancic RJ, Idicula WK, deSilva BW. Strap Muscle Type I Thyroplasty After Gore-Tex Implant Extrusion: Case Report and Literature Review. J Voice 2019; 34:802-805. [PMID: 30981659 DOI: 10.1016/j.jvoice.2019.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To discuss the presentation and management techniques of implant extrusion following type I thyroplasty and to illustrate the potential of strap muscle for augmentation following implant removal. METHODS We report a unique case of a patient with late Gore-Tex implant extrusion after type I thyroplasty treated with removal and autologous strap muscle graft for augmentation. RESULTS A 41-year-old female nearly 3.5 years status post Gore-Tex type I thyroplasty for left vocal fold paralysis presented for evaluation of dysphonia. Upon flexible laryngoscopy, erythema, edema, and granulation tissue were identified at the left vocal fold and ventricle. The patient subsequently underwent removal of her implant. Intraoperatively, a free portion of sternothyroid muscle was dissected free and placed into the paraglottic space. One month following surgery, the patient reported an improvement in her Voice Handicap Index (VHI) score from 40 to 0. In addition, no major complications were observed and complete glottic closure was achieved. Nine months postsurgery, she continued to function well with a VHI score of 0. At 50 months postop, the patient still reports a VHI score of 0. CONCLUSIONS Implant extrusion is a rare complication of type I thyroplasty usually occurring in the first few months after surgery and more commonly presenting in females. Current management options consist of observation or augmentation with autologous fat or vocal fold injection following implant removal. This is the first report of a successful strap muscle free graft revision thyroplasty following implant extrusion. The patient's excellent long-term outcome highlights the potential of strap muscle augmentation as a feasible management option for implant extrusion.
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Affiliation(s)
- Rishabh Sethia
- Department of Otolaryngology, Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; College of Medicine, The Ohio State University, Columbus, Ohio
| | - Ryan J Ivancic
- College of Medicine, The Ohio State University, Columbus, Ohio
| | - Winslo K Idicula
- Department of Pediatric Otolaryngology, Head and Neck Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Brad W deSilva
- Department of Otolaryngology, Head and Neck Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; College of Medicine, The Ohio State University, Columbus, Ohio.
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Tsai MS, Yang YH, Liu CY, Lin MH, Chang GH, Tsai YT, Li HY, Tsai YH, Hsu CM. Unilateral Vocal Fold Paralysis and Risk of Pneumonia: A Nationwide Population-Based Cohort Study. Otolaryngol Head Neck Surg 2018; 158:896-903. [PMID: 29405850 DOI: 10.1177/0194599818756285] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To investigate pneumonia risk among patients with unilateral vocal fold paralysis (UVFP). Study Design Retrospective population-based cohort study. Setting This study used data from the National Health Insurance Research Database of Taiwan, a nationwide population-based database. Subjects and Methods A total of 419 patients newly diagnosed with UVFP between January 1, 1997, and December 31, 2013, were identified from the Longitudinal Health Insurance Database 2000, a nationally representative database of 1 million randomly selected patients. Moreover, 1676 patients without UVFP were matched to patients with UVFP at a 1:4 ratio based on age, sex, socioeconomic status, urbanization level, and site-specific cancers. Patients were followed up until death or the end of the study period (December 31, 2013). The primary outcome was the occurrence of pneumonia. Results The cumulative incidence of pneumonia was significantly higher for patients with UVFP than those without UFVP ( P < .001). The adjusted Cox proportional hazard model showed that UVFP was significantly associated with a higher incidence of pneumonia (hazard ratio, 1.97; 95% CI, 1.35-2.86; P < .001). Subgroup analyses demonstrated that UVFP was an independent risk factor of pneumonia for 4 subgroups: young (18-50 years), older (≥51 years), male, and cancer. Conclusion This is the first nationwide population-based cohort study to investigate the association between UVFP and pneumonia. The findings indicate that UVFP is an independent risk factor of pneumonia. Given the study results, physicians should be aware of the potential for pneumonia occurrence following UVFP.
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Affiliation(s)
- Ming-Shao Tsai
- 1 Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,2 Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yao-Hsu Yang
- 2 Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan.,3 Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Taipei, Taiwan.,4 Department of Traditional Chinese Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,5 School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Yen Liu
- 2 Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Meng-Hung Lin
- 2 Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Geng-He Chang
- 1 Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yao-Te Tsai
- 1 Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Hsueh-Yu Li
- 6 Department of Otolaryngology-Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,7 Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ying-Huang Tsai
- 8 Division of Pulmonary and Critical Care Medicine, Department of Respiratory Care, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,9 Department of Respiratory Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Ming Hsu
- 1 Department of Otolaryngology-Head and Neck Surgery, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,5 School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,10 Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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