Arytenoid adduction combined with Gore-Tex medialization thyroplasty

Systematic Review and Meta-Analysis of Outcomes in Type 1 Thyroplasty Comparing Silastic to Gore-Tex

OBJECTIVE

Type 1 Thyroplasty is a well-established procedure used for medializing an immobile vocal fold. Silastic and Gore-Tex are the two most common materials used to accomplish this, but comparative data on their relative efficacy are scarce. We sought to compare outcomes between Silastic and Gore-Tex implants via systematic review and meta-analysis for unilateral vocal fold immobility.

METHODS

We collected available data from PubMed, Embase, and Web of Science on demographics, maximum phonation time (MPT), voice handicap index (VHI-10/30) score, and any other relevant metrics encountered before comparatively evaluating differences in outcomes.

RESULTS

The search yielded 1,534 records with 55 manuscripts ultimately included. There were 41 unique studies that utilized Silastic for a total of 1038 patients. There were 13 unique studies that utilized Gore-Tex for a total of 245 patients. The pooled mean increase in MPT for Silastic patients was 7.8 s (+1.3 SMD) compared with 5.7 s for Gore-Tex (+1.6 SMD). There was significant publication bias present in both analyses. The pooled mean change in VHI-30 with Silastic was -45.4 (62.2%, -2.09 SMD) compared with -51.6 (73.5%, -1.1 SMD) with Gore-Tex. The pooled mean change in VHI-10 with Silastic was -15.6 (54%, -0.46 SMD) compared with -11.6 (43%, -0.86 SMD) with Gore-Tex. There was no significant publication bias present in VHI outcomes.

CONCLUSIONS

Silicone and Gore-Tex implants provide adequate and comparable results in TT1. The data supporting this conclusion are limited by follow-up, diversity in outcomes, limited data availability, and publication bias. Future research should be dedicated to comparing implants in a well-randomized environment. Laryngoscope, 2024.

Complications and Revisions for Adduction Arytenopexy, Medialization Laryngoplasty, and Cricothyroid Subluxation over 19 Years

OBJECTIVE

To report the long-term data of the Triple procedure (medialization laryngoplasty, adduction arytenopexy, and cricothyroid subluxation) regarding complications and revisions in a large cohort of patients.

STUDY DESIGN

Retrospective case series.

METHODS

This study included patients who underwent ≥1 components of the Triple procedure between January 2000 and July 2019. Demographic data, etiology of paralysis, duration of follow-up, complications, revision surgeries, and touch-up injections were noted from retrospective chart review.

RESULTS

Of the 222 patients who underwent ≥1 of the Triple procedure components, 86 underwent medialization laryngoplasty alone and were excluded from the study. The remaining 136 underwent ≥1 components of the Triple procedure other than medialization laryngoplasty alone. The overall surgical complication rate was 7.3% (10/136) and no intraoperative complications were noted. Of the 10 complications, four were implant extrusions, four were hematoma, and two were rupture of the arytenoid fixation suture. In all, 20 of the 136 cases subsequently required revision surgery (14.7%) at a mean of 57.3months after the initial surgery.

CONCLUSION

The present findings show that the Triple procedure, or its subcomponents, can be performed with few complications and acceptable revision rates.

Voice Outcome After Carbon Dioxide Transoral Laser Microsurgery for Glottic Cancer According to the European Laryngological Society Classification of Cordectomy Types - A Systematic Review

BACKGROUND

Voice outcome after carbon dioxide transoral laser microsurgery (CO2TOLMS) for glottic cancer is of prime importance. However, a comprehensive overview according to the European Laryngological Society (ELS) classification of cordectomies is still lacking. The aim of this systematic review is to summarize data on voice outcome associated with individual types of ELS glottic cordectomy after CO2TOLMS.

MATERIALS AND METHODS

A systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The initial search identified 936 records of which 25 publications were then included. Voice outcome data (Voice Handicap Index [VHI] version 30, grade of dysphonia [G] and maximum phonation time [MPT]) were extracted per resection type. Weighted averages were calculated.

RESULTS

Data show a gradual increase in the VHI scores although they were still similar for all cordectomy types (range 14.2 to 21.5). The grade of dysphonia showed a gradual increase with increasing resection depth (range 1.0 to 1.9). There was a gradual decrease in the MPT (range 15.2 to 7.2).

CONCLUSION

Voice outcome is related to cordectomy type with mild dysphonia characterizing ELS type I, II and III cordectomies, while more extended cordectomies (ELS type IV, V and VI) result in moderate dysphonia and shortness of breath during phonation. The voice handicap experienced by patients is limited even in the more extended cordectomies.

Fenestration Approach for Arytenoid Adduction in Unilateral Vocal Fold Paralysis

OBJECTIVE

Several surgical techniques have been reported for the treatment of unilateral vocal fold paralysis (UVFP). Although the fenestration approach has recently been applied for arytenoid adduction (AA) in some cases, long-term large-cohort studies on its usefulness are lacking. Therefore, this study aimed to evaluate the long-term voice outcomes of this technique in patients with UVFP.

STUDY DESIGN

Retrospective study.

METHODS

A total of 168 patients with UVFP underwent laryngoplasty comprising AA performed through fenestration of the thyroid ala combined with a type I thyroplasty (TPI). The maximum phonation time (MPT) and mean airflow rate (MFR) were measured before and after surgery, and voice analysis included an estimation of shimmer and jitter. Anterior and posterior surgical windows were created in the lower thyroid ala and were used for typical TPI and AA, respectively. The window locations were determined based on three-dimensional computed tomography data. AA was performed by pulling the muscular process of the arytenoid cartilage toward the lateral cricoarytenoid muscle through the posterior window without releasing the cricothyroid joint. All surgeries were performed under local anesthesia, and medialization was endoscopically confirmed.

RESULTS

Postoperative MPT >10 seconds was achieved in 156 of the 168 patients. Postoperatively, MFR improved to <250 mL/s in all but two patients, and MPT, MFR, jitter, and shimmer significantly improved in all patients. Furthermore, perceptual evaluation using the Grade, Roughness, Breathiness, Asthenia, and Strain scale revealed significant improvement in all patients.

CONCLUSIONS

The fenestration approach preserves the cricothyroid joint and does not open the cricoarytenoid joint; therefore, the laryngeal cartilage is stabilized, and no distortion of the laryngeal framework occurs. Our results showed that combined AA and TPI via the fenestration approach provided stable long-term postoperative voice improvement in patients with UVFP.

LEVEL OF EVIDENCE

Level 3.

Safety and Adverse Events of Medialization Thyroplasty: A Systematic Review

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.

Voice outcome in medialisation thyroplasty with and without arytenoid adduction: a prospective comparison using intraoperative voice measurements

PURPOSE

Arytenoid adduction as an addition to medialisation thyroplasty is highly advocated by some surgeons in selected cases but deemed less necessary by others in patients with unilateral vocal fold paralysis. This study aims to evaluate the additional benefits on voice outcome of arytenoid adduction in patients with unilateral vocal fold paralysis undergoing medialisation thyroplasty using intra-operative voice measurements.

DESIGN/METHODS

A prospective study was conducted. Voice audio recordings were obtained at 4 moments; 1. direct prior to the start of surgery, 2. during surgery after medialisation thyroplasty, 3. during surgery after medialisation and arytenoid adduction, 3 months postoperative. At these same timepoints patients rated their own voice on a numeric rating scale between 0 and 10. The blinded recordings were rated by consensus in a team of experienced listeners, using the Grade of the GRBAS scale. Furthermore, the Voice Handicap Index was administered before and at 3 months after surgery.

RESULTS

Ten patients who underwent medialisation and arytenoid adduction at our tertiary referral hospital between 2021 and 2022, were included. One patient was excluded after surgery. The intraoperative measurements showed a Grade score of 1.4 preoperatively, improving to 1.2 after medialisation, 1.2 after medialisation and arytenoid adduction, and further improving to 0.4 at 3 months postoperative, which was a not statistically significant improvement (p = 0.2). The intraoperative subjective numeric rating scale showed a statistically significant improvement from 3.9 preoperatively, to 6.1 after medialisation, 7.1 after medialisation and arytenoid adduction and a 7.6 at 3 months postoperative (p = 0.001). The Voice Handicap Index total score showed a statistically significant improvement from 71 points before surgery to 13 at 3 months after surgery (p = 0.008).

CONCLUSIONS

Our study using intraoperative voice measurements indicate that the addition of arytenoid adduction to medialisation thyroplasty is a benefit in selected patients although more studies are needed due to the many limitations inherent to this field of investigation.

Preliminary Experience with 3-Dimensional Exoscope-Assisted Laryngoplasty

OBJECTIVE

Laryngoplasty requires the manipulation of the vocal folds, which are not visible during the operation. The widespread use of this technique is limited by the need for adequate knowledge of anatomy, the small surgical field, and the high level of skill required for the procedure. An exoscope has been developed to provide a stereoscopic view similar to that of a microscope while using the same compact endoscopic tool. This study aimed to determine whether the three-dimensional (3D) exoscopic surgical technique could be applied to laryngoplasty and explore its possibility to ultimately replace the current approach.

METHODS

This was a retrospective case series analysis, which included 28 patients with hoarseness who underwent surgery with (Exoscope; n = 12) or without (Macrosurgery; n = 16) a 3D exoscope between July 2018 and February 2021. The feasibility of performing all surgical steps with the 3D exoscope was evaluated. The Exoscope and Macrosurgery groups were compared for surgical time, vocal function outcomes, and complications. Questionnaires were completed by medical staff regarding the usefulness of medical education.

RESULTS

No intraoperative or postoperative complications occurred in either procedure. The operative time was similar in both groups. The vocal function outcomes were also comparable between the groups. Questionnaires revealed that the exoscope was useful in terms of sharing information on surgical procedures and anatomy, as well as functioning as an educational tool.

CONCLUSION

While this was a preliminary study, our results indicated that the exclusive use of the 3D exoscope was feasible for open approaches.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1813-1819, 2024.

Electrical Stimulation of Vocal Fold Adduction Triggered by Laryngeal Electromyography Using a Custom Implant

PURPOSE

Medialization procedures for unilateral vocal fold (VF) paralysis generally improve voice but do not fully replace dynamic VF adduction. Paralyzed VFs typically experience synkinetic reinnervation, which makes it feasible to elicit movement through electrical stimulation. We tested a novel laryngeal pacing implant capable of providing closed-loop (automatic) stimulation of a VF triggered by electromyography (EMG) potentials from the contralateral VF.

METHOD

A custom, battery-powered, microprocessor-based stimulator was tested in eight dogs with bipolar electrodes implanted for recording EMG from the left VF and stimulating adduction of the right VF. A cuff electrode on the left recurrent laryngeal nerve (RLN) stimulated unilateral VF adduction, modeling voluntary control in anesthetized animals. Closed-loop stimulation was tested in both acute and chronic experiments. Synkinetic reinnervation was created in two animals by right RLN transection and suture repair to model unilateral VF paralysis.

RESULTS

In all animals, left VF activation through RLN stimulation generated a robust EMG response that rapidly triggered stimulation of contralateral thyroarytenoid and lateral cricoarytenoid muscles, causing nearly simultaneous bilateral adduction. Optimal triggering of VF stimulation from elicited EMG was achieved using independent onset and offset thresholds. Real-time artifact blanking allowed closed-loop stimulation without self-perpetuating feedback, despite the proximity of recording and stimulation electrodes.

CONCLUSIONS

Using a custom implant system, we demonstrated real-time closed-loop stimulation of one VF triggered by the activation of the contralateral VF. This approach could potentially restore dynamic glottic closure for reflexive behaviors or phonation in cases of unilateral VF paralysis with synkinetic reinnervation.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24492133.

Long-term voice evaluation after arytenoid adduction surgery in patients with unilateral vocal fold paralysis

PURPOSE

Laryngeal framework surgery, including medialization laryngoplasty and arytenoid adduction (AA), is expected to have a lasting or permanent effect in patients with unilateral vocal fold paralysis (UVFP); however, there are few reports about the long-term outcomes of AA. This study aimed to evaluate the long-term postoperative effects of AA surgery and examine its stability and reliability.

METHODS

This study collected the voice handicap index (VHI) questionnaire from patients with UVFP who underwent AA more than 2 years previously. The VHI values preoperatively and 3 months postoperatively (early postoperative evaluation) were retrospectively calculated, and VHI values more than 2 years after surgery (late postoperative evaluation) were collected by mailing a sheet to the patients and asking to fill and return it. Possible influenced subscales such as age, sex, causes of UVFP, affected side, and surgeons were also analyzed.

RESULTS

A total of 77 patients with UVFP who underwent AA had significantly lower early and late postoperative evaluations than preoperative evaluations. In 38 patients with no missing values, there were no significant differences between early and late postoperative evaluations, measured at a median of approximately 5 years. There were also no significant differences between early and late postoperative evaluations in any of the subscale groups.

CONCLUSION

Patients with UVFP who underwent AA surgery achieved stable voice improvement in the long term after surgery.

Effectiveness of vocal fold medialization surgery on the swallowing function of patients with unilateral vocal fold paralysis

Objectives

Vocal fold medialization surgery is generally considered a phonosurgical procedure for improvement of vocal function in patients with glottic insufficiency. However, the literature describing this procedure for the management of dysphagia is limited. This study aims to assess the effects of medialization surgery on swallowing function in patients with unilateral vocal fold paralysis (UVFP).

Methods

We enrolled 32 patients with UVFP undergoing vocal fold medialization surgery (medialization laryngoplasty combined with arytenoid adduction [ML + AA], 12 cases; injection laryngoplasty [IL], 20 cases). We assessed the aerodynamic vocal function including maximum phonation time and mean flow rate to evaluate glottal closure status. The Hyodo score determined by flexible endoscopic evaluation and Functional Oral Intake Scale (FOIS) were evaluated pre- and postoperatively.

Results

Almost 60% of patients with UVFP had dysphagia, and one-third were at high risk for aspiration. Aerodynamic parameters effectively improved after IL and ML + AA. With regard to swallowing, both the FOIS and total Hyodo score were significantly improved postoperatively. We found a particularly significant improvement in pharyngeal clearance. However, patients with high vagal nerve paralysis and postoperative insufficient glottal closure showed poor swallowing benefits after the interventions. In patients with recurrent laryngeal nerve palsy, there were no significant differences in postoperative swallowing function between the ML + AA and IL groups.

Conclusion

Vocal fold medialization surgery was effective in improving swallowing function in most cases with UVFP, except for those with high vagal paralysis and insufficient postoperative glottal closure. Both IL and ML + AA showed an equivalent effect on swallowing improvement.

Level of evidence

3b.

An Ex-vivo Model Examining Acoustics and Aerodynamic Effects Following Medialization With and Without Arytenoid Adduction

OBJECTIVES/HYPOTHESIS

Quantify differences in acoustics and intraglottal flow fields between Thyroplasty Type 1 (TT1) with and without arytenoid adduction (AA) using excised canine larynx model.

STUDY DESIGN

Basic science experiments using excised larynges.

METHODS

Surgical procedures were implemented in eight excised canine larynges. Acoustics and intraglottal flow measurements were taken at low and high subglottal pressures in each experimental setup.

RESULTS

In all larynges, vocal efficiency (VE) and cepstrum peak prominence (CPP) were higher, and the mean phonatory flow rate was lower in TT1 with AA than without AA. The glottal asymmetry is reduced with AA and promotes the formation of stronger vortices in the glottal flow during the closing phase of the vibrating folds.

CONCLUSIONS

Findings suggest a clear acoustic and aerodynamic benefit to the addition of AA when performing TT1. It shows significant improvement in CPP, translating to decreased breathiness and dysphonia and increased VE, leading to easier and more sustainable phonation. Stronger intraglottal vortices are known to be correlated with the loudness of voice produced by phonation.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:621-627, 2023.

Impact on swallowing functions of arytenoid adduction in patients with unilateral vocal fold paralysis

OBJECTIVE

Although the pathophysiology of swallowing dysfunction in patients with unilateral vocal fold paralysis (UVFP) remains uncertain, glottal insufficiency is known to be a possible major cause, and other factors due to vagus nerve or recurrent laryngeal nerve damage may contribute to dysphagia or aspiration. This study aimed to evaluate the effect of arytenoid adduction (AA) surgery on the swallowing functions of UVFP patients and to investigate the important role of glottic closure during swallowing.

METHODS

We prospectively analyzed the data of thirteen patients with UVFP who underwent AA in combination with medialization laryngoplasty (ML) for improving voice quality. The subjects received a series of examinations for not only voice function but also swallowing function and cough strength both preoperatively and approximately 6 months after surgery. The evaluations of voice function included the Voice Handicap Index and aerodynamic measures; the evaluations of swallowing function included the Eating Assessment Tool-10, liquid aspiration, a videofluorographic examination of swallowing study, and high-resolution manometry; and the evaluation of cough strength included the measurement of cough peak flow. All measurements before and after surgery were statistically compared and examined.

RESULTS

Considerable improvements in voice measures were observed after the procedure, as sufficient glottic closure was achieved during phonation and swallowing. In terms of swallowing evaluation, there were significant differences in the subjective assessment methods after the operation. Additionally, our intervention improved two cases of aspiration according to abnormal findings on the videofluorographic examination of swallowing. There was a significant difference in cough peak flow, with all participants having better values after surgery. High-resolution manometry revealed no significant differences between pre- and postsurgery in any parameters at the level of the mesopharynx or upper esophageal sphincter.

CONCLUSION

The findings of our study suggest an important effect on the dysphagia of UVFP patients who undergo AA combined with ML. In addition, we revealed improvements in swallowing by strengthening incomplete glottic closure; thus, we consider that sufficient glottic closure must play an important role in swallowing function in patients with UVFP.

Medialization Laryngoplasty After Endoscopic Laser Cordectomy. Our Experience

PURPOSE

Medialization laryngoplasty can be performed to treat glottic incompetence after endoscopic laser cordectomy. The aim of this study is to evaluate vocal outcome after this phonosurgical procedure and to analyze the critical aspects of the Montgomery and Gore-Tex laryngoplasty technique.

METHODS

A retrospective observational study of patients with glottic incompetence after endoscopic laser cordectomy, underwent medialization laryngoplasty with Montgomery or Gore-Tex implant between January 2013 to December 2018 at the Bufalini Hospital of Cesena, Italy. The pre- and postphonosurgery evaluation included videolaryngostroboscopy, perceptual, evaluation of dysphonia with the GRBAS (grade, roughness, breathiness, asthenia, strain) scale, Voice Handicap Index-10, Maximum Phonation Time. The outcome was evaluated 6 months after the phonosurgical treatment.

RESULTS

We treated 22 patients, 19 males and 3 females. Eight cases were treated with Montgomery implant and fourteen with Gore-Tex implant. The postphonosurgical videolaryngostroboscopy showed an improvement of the glottic closure in all patients; the scores of the Voice Handicap Index-10 and of the Maximum Phonation Time showed a statistically significant improvement after phonosurgery. The GRBAS scale scores showed a statistically significant improvement of Global Grade, Breathiness, and Asthenia; the parameter Strain remained unaltered both in pre- and postoperative evaluations, because the voice was never pressed due to glottic insufficiency, especially in preoperative observation. The parameter Roughness (R) did not show a significant difference between pre- and postoperative evaluation.

CONCLUSION

Medialization laryngoplasty is an effective phonosurgical procedure to improve voice outcome, after extended endoscopic laser cordectomies, in patients with unacceptable results after voice therapy and injection laryngoplasty. In our experience the Gore-Tex implant allows the surgeon to perform a safer and more "tailored" phonosurgery in cases of cordectomies type IV and V, associated or not with radiotherapy and in revision surgery.

Long-term voice outcomes of laryngeal framework surgery for unilateral vocal fold paralysis

OBJECTIVE

To evaluate the short- and long-term voice outcomes after unilateral medialization thyroplasty (MT) and unilateral medialization thyroplasty with arytenoid adduction (MT + AA) in patients with unilateral vocal fold paralysis.

METHODS

Voice outcomes were assessed preoperatively, and postoperatively at 3 and 12 months according to a standardized protocol. Voice assessment was performed using Voice Handicap Index (VHI), GRBAS Grade, Maximum Phonation Time (MPT), s/z-ratio and subjective numeric rating scales on voice quality, effort, performance and influence on life.

RESULTS

Sixty-one patients were included (34 MT and 27 MT + AA). Significant pre- to postoperative improvements were seen in all voice outcome parameters. No significant differences in post-operative values were identified between the groups.

CONCLUSION

Based on our findings, we conclude that patients with unilateral vocal fold paralysis who undergo MT and MT + AA achieve comparable and significant long time voice improvement, although voices do not completely normalize. We also conclude that this does not mean that AA is a superfluous procedure, but can indicate the accurate identification of patients in need of the additional AA procedure based on clinical parameters.

Safety and Predictors of 30-Day Adverse Events of Laryngeal Framework Surgery: An Analysis of ACS-NSQIP data

OBJECTIVES/HYPOTHESIS

To characterize and identify predictors of 30-day adverse events in patients undergoing laryngeal framework surgery (LFS).

STUDY DESIGN

This study is a retrospective analysis of the National Surgical Quality Improvement dataset.

METHODS

LFS cases were identified from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from 2008 to 2018. Demographic variables, patient comorbidities, and perioperative outcomes (any adverse event, 30-day readmission, 30-day reoperation, and unplanned intubation) were extracted. Patient-specific and surgery-specific factors associated with perioperative adverse events were examined using descriptive statistics and univariate logistic regression (LR).

RESULTS

Of 283 patients who underwent LFS, 225 underwent laryngoplasty medialization, 56 underwent laryngoplasty medialization with arytenoidectomy or arytenoidopexy via an external approach, and 2 underwent local myocutaneous or fasciocutaneous advancement flap along with laryngoplasty. Medical comorbidities were present in 33.6% of patients and 57.9% were American Society of Anesthesiologists (ASA) Class III/IV (57.9%). LFS was performed as same-day surgery in 30.7% of cases. Fourteen patients (4.9%) suffered an adverse condition within 30 days following surgery. In univariate LR, ASA Class III or IV (odds ratio [OR] 4.6, 95% confidence interval [CI] 1.2-30.1) was the only predictor associated with any adverse event. Arytenoid adduction (AA) was associated with increased risk of reoperation within 30 days of the initial surgery (OR 6.4, 95% CI 1.0-49).

CONCLUSIONS

LFS is a generally safe procedure with infrequent perioperative adverse events. In the ACS-NSQIP database, ASA classification of III or IV was associated with a higher risk for any 30-day adverse event and AA was associated with a higher risk for 30-day reoperation.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Unilateral Vocal Fold Paralysis With Large Posterior Glottic Gap: Is Arytenoid Procedure Necessary?

OBJECTIVES

For unilateral vocal fold paralysis (UVFP) with large posterior glottic gap medialization laryngoplasty (ML) + arytenoid adduction (AA), ML + adduction arytenopexy (AApexy), and ML alone using prosthesis with posterior extension are possible solutions. This study was carried out to elucidate the controversy among these solution options.

METHODS

Retrospective cohort. Tertiary referral center. One hundred forty patients with UVFP with large posterior glottic gap. Group 1 had 30 patients with ML + AA; Group 2 had 25 patients with ML + AApexy; Group 3 had 29 patients with ML using Isshiki prosthesis; Group 4 had 26 patients with ML using Montgomery prosthesis; Group 5 had 30 patients with ML using prosthesis with large posterior extension. Glottic closure using videolaryngostroboscopy, GRBAS, VHI-30, EAT-10, acoustic and aerodynamic analysis was carried out pre- and 1-year-postoperatively.

RESULTS

Preoperatively there was no significant difference in any parameters studied among all study groups (P > .05). Except F0, speaking F0 and EAT-10, all other parameters in acoustic and aerodynamic analysis, glottic closure, GRBAS, and VHI-30 scores were significantly better postoperatively in Groups 1 and 2 compared to Groups 3 to 5 (P < .05).

CONCLUSIONS

In patients with UVFP and large posterior glottic gap, ML + AA and ML + AApexy seem to do better subjectively and objectively, acoustically and aerodynamically, when compared to ML using prosthesis with and without large posterior extension. ML alone does not appear to close posterior glottic gap. Therefore, it is a better and more reasonable option to perform arytenoid procedure when there is large posterior glottic gap in UVFP.

Care and Management of Voice Change for Thyroid Surgery: Korean Society of Laryngology, Phoniatrics and Logopedics Clinical Practice Guideline

Voice change is a common complaint after thyroid surgery and has significant impacts on quality of life. The Korean Society of Laryngology, Phoniatrics, and Logopedics set up a task force team to establish guideline recommendations on education, care, and management related to thyroid surgery. The guideline recommendations include preoperative voice education, management of anticipated voice change during surgery, and comprehensive voice care after thyroid surgery, including in-depth information and up-to-date knowledge based on validated literature. The committee constructed 14 key questions (KQ) in three categories: preoperative (KQ1-2), intraoperative (KQ 3-8), and postoperative (KQ 9-14) management and developed 18 evidence-based recommendations. The Delphi survey reached an agreement on each recommendation. Detailed evidence profiles are presented for each recommendation. The level of evidence for each recommendation is classified into high, moderate, and low-quality. The recommendation's strengths are adjusted to consider the level of evidence resulting in the recommendation and are divided into strong and weak. The guidelines are primarily targeted toward physicians who treat thyroid surgery patients and speech-language pathologists participating in patient care. These guidelines will also help primary care physicians, nurses, healthcare policymakers, and patients improve their understanding of voice changes and voice care after thyroid surgery.

Arytenoid asymmetry: Is it the most predictive parameter for arytenoid adduction in unilateral vocal fold paralysis?

OBJECTIVE

The aim of this study was to establish arytenoid asymmetry as a pre-operative predictive parameter for arytenoid adduction surgery in unilateral vocal fold paralysis and thereafter identify the most predictive parameter for arytenoid adduction among the established parameters.

METHODS

A retrospective comparative study was undertaken. The 'arytenoid asymmetry angle' formed between skewed 'glottic' and 'interarytenoid' axes (traced along the plane of closure of the membranous and cartilaginous glottis, respectively) was quantified in pre-operative laryngoscopic images of 85 adults with unilateral vocal fold paralysis who underwent either type 1 thyroplasty (group 1) or type 1 thyroplasty with arytenoid adduction (group 2). The need for arytenoid adduction was determined intra-operatively based on subjective voice improvement and laryngoscopic results.

RESULTS

Arytenoid asymmetry (p < 0.0001), posterior phonatory gap (p = 0.001) and vertical level difference (p = 0.004) were significantly greater in group 2 (descending order of parameters). Arytenoid asymmetry angle showed a significant positive correlation with the latter two parameters.

CONCLUSION

Arytenoid asymmetry is the most predictive parameter for arytenoid adduction. An arytenoid asymmetry angle of more than or equal to 33.9⁰ is an indication for arytenoid adduction. This aids in pre-operative planning of arytenoid adduction.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4.

Pre- and intraoperative acoustic and functional assessment of the novel APrevent® VOIS implant during routine medialization thyroplasty

PURPOSE

Persistent unilateral vocal fold paralysis (UFVP) with glottal insufficiency often requires type I medialization thyroplasty (MT). Previous implants cannot be adjusted postoperatively if necessary. The newly developed APrevent^® VOIS implant (VOIS) can provide postoperative re-adjustment to avoid revision MT. The objective of this pilot study is to evaluate the VOIS intraoperatively concerning voice improvement, surgical feasibility and device handling.

METHODS

During routine MT, VOIS was applied short time in eight patients before the regular implantation of the Titanium Vocal Fold Medialization Implant (TVFMI™). In all patients, perceptual voice sound analysis using R(oughness)-B(reathiness)-H(oarseness)-scale, measurement of M(aximum)-P(honation)-T(ime) and glottal closure in videolaryngoscopy were performed before and after implanting VOIS/TVFMI™. Acoustic analyses of voice recordings were performed using freeware praat. Surgical feasibility, operative handling and device fitting of VOIS and TVFMI™ were assessed by the surgeon using V(isual)-A(nalog)-S(cale). Data were statistically analyzed with paired t test.

RESULT

All patients showed significant improvement of voice sound parameters after VOIS/TVFMI™ implantation. The mean RBH-scale improved from preoperative R = 2.1, B = 2.3, H = 2.5 to R = 0.6, B = 0.3, H = 0.8 after VOIS and R = 0.5, B = 0.3, H = 0.8 after TVFMI™ implantation. The mean MPT increased from preoperative 7.9 to 14.6 s after VOIS and 13.8 s after TVFMI™ implantation. VOIS/TVFMI™ achieved complete glottal closure in 7/8 patients. The satisfaction with intraoperative device fitting and device handling of VOIS was as good as that of TVFMI™.

CONCLUSION

The novel APrevent^® VOIS implant showed similar intraoperative voice improvement compared to routinely used TVFMI™ without adverse device events and with safe device fitting.

Role of Postoperative Antibiotics in Patients Undergoing Type I Thyroplasty with Gore-Tex Implant

OBJECTIVES

The purpose of this study was to determine the need for postoperative antibiotic administration in patients undergoing type I thyroplasty performed with Gore-Tex implant.

STUDY DESIGN

Retrospective analysis.

METHODS

Medical records of patients from a quaternary care laryngology practice who underwent type I thyroplasty for glottic insufficiency using Gore-Tex (W.L. Gore, Newark, Delaware) implant between the years 2013 and 2019 were reviewed retrospectively. Subjects were divided into two groups determined by those who did or did not receive routine postoperative antibiotics. All patients received two grams of cefazolin IV (for the standard 70-kilogram patient), and 10 mg of dexamethasone as a one-time dose given 10 minutes prior to incision. Patients allergic to cefazoline who received a single preoperative dose of 600 mg of clindamycin IV. All subjects were seen in the office at least three times after the procedure: one day, one week, and approximately six weeks following surgery. Statistical analysis was performed on the collected data using χ² analysis for categorical data and a student t test for means. A P value of less than 0.01 was considered significant.

RESULTS

There was no significant difference in infection rate or other complications between groups.

CONCLUSION

Routine use of antibiotics following type I thyroplasty with Gore-Tex (W.L. Gore, Newark, Delaware) appears unnecessary.

Voice outcomes following medialization laryngoplasty with and without arytenoid adduction

OBJECTIVE

Voice outcomes following medialization laryngoplasty (ML) for unilateral vocal fold paralysis (UVFP) were compared to those who underwent ML plus arytenoid adduction (AA) (ML+AA).

METHODS

Single institution retrospective review of patients with UVFP undergoing ML and ML+AA (2009-2017). Demographic information and history of laryngeal procedures were collected. Preoperative and postoperative Voice Handicap Index-10 (VHI-10) and Consensus Perceptual Auditory Evaluation of Voice (CAPE-V) were assessed.

RESULTS

Of 236 patients, 119 met study criteria. Of those, 70 (59%) underwent ML and 49 (41%) underwent ML+AA. Significant differences between groups at baseline were found for age at time of thyroplasty (P = 0.046), VHI-10 scores (P < 0.001), and CAPE-V scores (P = 0.007). Baseline VHI-10 scores for ML+AA (28 ± 7) were greater than those for ML alone (24 ± 7). At 12 months, overall VHI-10 scores improved compared to baseline for both groups (ML+AA = 9 ± 7, ML = 16 ± 9); however, there was greater improvement for the ML+AA group compared to ML group (P = 0.001). CAPE-V scores at 3 or 12 months improved, but differences between the groups were not statistically significant once controlled for covariates.

CONCLUSION

Based on current findings, patients who undergo ML+AA likely have greater voice handicap at baseline compared to those undergoing ML alone. Patients selected for ML+AA improve as much or more than those who underwent ML alone. This highlights the importance of appropriate selection of candidates for AA.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1876-1881, 2019.

Outcomes of medialization laryngoplasty with and without arytenoid adduction

OBJECTIVES/HYPOTHESIS

To evaluate the effect of medialization laryngoplasty (ML) performed alone compared to ML with arytenoid adduction (AA) on glottic gap and voice quality in unilateral vocal fold paralysis (UVFP) patients.

STUDY DESIGN

Retrospective case series.

METHODS

UVFP patients treated with ML alone and ML with AA at the University of California San Francisco Voice and Swallowing Center were identified. Demographic information and history of laryngeal procedures were collected. Preoperative and postoperative examinations were digitally analyzed using ImageJ for normalized anterior and posterior glottic gap and voice samples graded with CAPE-V scores.

RESULTS

Forty-seven patients underwent ML and 27 patients underwent ML with AA. Normalized anterior gap (AG) improved in both ML (preop: 4.4 pixel units (u), postop: 0.8 u; P < 0.001) and ML with AA groups (preop: 3.3 u, postop 0.6 u; P < 0.001). There was no statistically significant difference in normalized AG values between treatment groups. Postoperative normalized posterior gap (PG) improved in the ML with AA group only (preop: 1.8 u, postop: 0.5 u; P = 0.01). Overall severity, roughness, and strain voice parameters had acceptable reliability for analysis. Overall severity improved in ML (preop: 54, postop: 27; P < 0.001) and ML with AA (preop: 44, postop: 24; P = 0.005). There was no statistically significant difference in any voice parameter between treatment groups.

CONCLUSION

UVFP patients undergoing ML may benefit from addition of AA when a large posterior glottic gap is present. In this study, ML with AA but not ML alone resulted in statistically significant improvement in PG.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2591-2595, 2017.

Modifications to the Fenestration Approach for Arytenoid Adduction Under Local Anesthesia

OBJECTIVE

We modified the fenestration approach for arytenoid adduction to make it easier to perform the surgery. The aim of this study was to evaluate the usefulness of our modifications, which included (1) use of an Alexis wound retractor (Applied Medical) to secure the surgical field through a small incision, and (2) use of a 12-mm, 1/2 R, insert-molded taper needle with 3-0 nylon suture to prevent damage to the arytenoid cartilage.

STUDY DESIGN

This is a retrospective non-randomized observational cross-sectional study.

METHODS

We compared the operative time and skin incision length between the conventional fenestration approach and our modified procedure, and verified the improvement of patients' voice by our procedure.

RESULTS

Seven patients underwent the conventional fenestration approach for arytenoid adduction with type I thyroplasty, whereas nine patients underwent our modified fenestration approach for arytenoid adduction with type I thyroplasty. The skin incision length with our modifications (median, 3.0 cm; interquartile range [IQR], 3.0-4.0) was significantly shorter than with the conventional procedure (median, 5.0 cm; IQR, 4.3-5.8) (P = 0.001). The operative time with our modifications (median, 95 minutes; IQR, 90-100) was significantly shorter than without our modifications (median, 115; IQR, 100-130) (P = 0.035). All patients who underwent our modified fenestration approach for arytenoid adduction had maximum phonation time greater than 11 seconds after surgery.

CONCLUSIONS

Our two distinctive modifications reduced the operative time and skin incision length for the fenestration approach, which improved the procedure by making it less invasive.

Long-term outcomes of type I thyroplasty with silicone implantation: Assessment of excised laryngeal tissue from a patient with secondary hypopharyngeal carcinoma

Here we describe the long-term outcomes of type I thyroplasty (TP-I) with silicone block implantation through histopathological assessments in a male patient who underwent pharyngolaryngectomy for secondary hypopharyngeal carcinoma 7 years after silicone implantation. A 66-year-old man presented with esophageal carcinoma and underwent subtotal esophagotomy. Subsequently, his left vocal fold exhibited fixation in a paramedian position, and he underwent TP-I with silicone block implantation 2 years after the primary esophageal surgery. His voice quality improved; however, he developed glottic carcinoma in the right vocal fold 6 months after TP-I and underwent laser cordectomy. Glottic carcinoma recurred 21 months later, and he underwent laser cordectomy again. Five years after the second laser surgery, he underwent pharyngolaryngectomy and neck dissection for hypopharyngeal carcinoma detected in the right pyriform sinus. We histopathologically examined a horizontal section of the resected larynx to assess silicone implant-related changes. Although migration of the silicone implant was not observed, a very mild foreign body reaction occurred around the implant. The patient is currently in remission. Our findings suggest that silicone implants are suitable for TP-I due to their remarkable affinity for human tissue and the low risk of a tissue reaction.

Laryngeal Framework Surgery in the Irradiated Neck: A Retrospective Matched Cohort Study

BACKGROUND

Laryngeal framework surgery (LFS) remains a cornerstone treatment in the management of glottic insufficiency. Traditionally, a history of radiation to the neck has been considered a relative contraindication to LFS.

METHODS

A retrospective matched cohort study was performed to study LFS outcomes in patients with and without a history of radiation. Variables studied included radiation specifics, surgical time, operative difficulty, complications, need for revision surgery, and Voice Handicap Index-10 (VHI-10) scores.

RESULTS

A total of 298 patients were studied. Fourteen patients with a history of neck irradiation were matched with 14 nonirradiated controls. No complications were encountered in the nonirradiated cohort. In the irradiated cohort, there were 2 minor wound complications and 1 admission for stridor treated medically. No cases of implant extrusion were observed. The VHI-10 scores were improved in both cohorts relative to preoperative baseline (P = .001). Posttreatment VHI-10 scores were better in the nonirradiated cohort (P = .03). There was no difference between cohorts with respect to complication rates, surgical time, surgical difficulty, length of stay, use of a surgical drain, or need for revision surgery.

CONCLUSION

Laryngeal framework surgery is safe and associated with improved voice outcomes in patients with a history of neck irradiation.

Endolaryngeal Extrusion of Expanded Polytetrafluoroethylene Implant after Medialization Thyroplasty

Various nonresorbable implants are currently used worldwide for medialization thyroplasty in patients with unilateral vocal cord paralysis. The Gore-Tex (expanded polytetrafluoroethylene) implant was introduced in the late 1990s. At our institution, 27 patients with unilateral laryngeal nerve paralysis had medialization thyroplasty with a Gore-Tex implant during the years 1998 to 2002. The current report documents our first case of endolaryngeal extrusion of a Gore-Tex implant.

Acoustic Analysis of Autologous Fat Injection versus Thyroplasty in the Same Patient

We objectively measured the acoustic effects of treatment of unilateral vocal fold paralysis by injection of autologous fat and by polytetrafluoroethylene thyroplasty, in the same patient. To our knowledge, this is the first report comparing the two techniques by using the patient's normal voice as the control. The voice of a male patient was recorded before and after onset of unilateral vocal fold paralysis, after treatment with autologous fat, and after polytetrafluoroethylene thyroplasty. Acoustic analysis was performed on a long-term average spectrum of text and on the MDVP (Kay Elemetrics) evaluation of the vowel /a/. Jitter and shimmer were not normalized, but they improved to a greater extent after fat injection. The cepstral peak prominence, spectral skewness, and long-term average spectrum returned to preparalytic values after both treatments, but improved to a greater extent after fat injection. This study showed that both techniques can return the voice to preparalytic values. Spectral measurements best reflected the voice improvement. Further prospective studies in a larger number of patients will be necessary to confirm these results and to determine the long-term objective voice outcome obtained with these techniques.

Revision Gore-Tex Medialization Laryngoplasty

OBJECTIVE: To evaluate the indications, results, and safety of revision Gore-Tex medialization laryngoplasty (GML).

METHODS: A retrospective chart review of 156 patients that underwent GML procedures between the years 1998–2002. Study population consisted of those patients who required revision surgery for any reason.

RESULTS: Sixteen patients required 22 revision procedures. Indications for revision were divided into 2 groups, complications and glottal closure problems. Complications included extruded or displaced implants (n = 4). The most common glottal closure problem was undercorrection (n = 9). Others included anterior overcorrection (n = 1) and persistent posterior glottal gap (n = 2). Revision procedures included GML (n = 9), injection augmentation (n = 9), endoscopic implant removal (n = 2), and arytenoid adduction (n = 2). In patients with glottal closure problems, the GCI improved in all 10 and the voice rating scale improved in 9.

CONCLUSION: Reasons for revision of GML are variable, the most common being undercorrection. A variety of safe, effective revision techniques are available with a high success rate.

Arytenoid adduction combined with nerve-muscle pedicle flap implantation or type I thyroplasty

OBJECTIVES/HYPOTHESIS

To evaluate vocal function after refined nerve-muscle pedicle (NMP) flap implantation with arytenoid adduction (AA) compared with type I thyroplasty with AA for patients with unilateral vocal fold paralysis (UVFP) and to evaluate the degree of patient satisfaction following the refined NMP with AA.

STUDY DESIGN

A retrospective review of clinical records of 52 patients with UVFP who received AA + NMP (NMP group, n = 40) or AA + type I thyroplasty (type I group, n = 12) as a single-stage operation between April 1999 and December 2011.

METHODS

Evaluation of vocal fold vibration, aerodynamic analysis, perceptual evaluation, acoustic analysis, and subjective assessment were performed preoperatively and at two different postoperative periods (short term: within 3 months and long term: >12 months).

RESULTS

All parameters except for glottal gap of the vocal fold vibration, maximum phonation time (MPT), and mean airflow rate revealed significant improvement between the short- and long-term assessments in the NMP group. On the contrary, the type I group did not show significant change of any parameters during postoperative periods. In the NMP group, the measurements for regularity of the vocal fold vibration and MPT at the long-term assessment were significantly favorable compared with the type I group. In the NMP group, subjective assessment (Voice Handicap Index-10 and Voice-Related Quality of Life) revealed significant improvement between the short- and long-term assessments.

CONCLUSIONS

In comparison with the type I group, significant improvement of vocal function patient satisfaction during the long-term follow-up period after AA combined with the refined NMP was confirmed.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:159-166, 2017.

Arytenoid repositioning device

OBJECTIVES

We report development of a device and technique to manage laryngeal paralysis through minimal-access arytenoid adduction (for unilateral paralysis) and arytenoid abduction (for bilateral paralysis).

METHODS

A human cadaver study coupled with directed engineering was used to develop instrumentation designed to secure the muscular process of the arytenoid into favorable adducted or abducted positions. Digital video, photography, and 3-dimensional computed tomographic (CT) imaging of cadaveric larynges were done to evaluate the surgical technique.

RESULTS

Testing of prototypes identified the ideal implant to be a 0.36-mm wire with a distal spring-wound coil placed through a trocar via a small drill hole in the anterior thyroid cartilage. An endoscopic view of transilluminated light through the pyriform sinus mucosa identified the tip location of the trocar adjacent to the muscular process of the arytenoid cartilage. Placement of the device through the trocar permitted rotation to engage the muscular process and/or adjacent soft tissue with the distal coil. Implant fixation to the thyroid cartilage positioned the vocal cord into either adduction or abduction. Three-dimensional CT imaging coupled with review of the video documentation established the feasibility of this technique.

CONCLUSIONS

We confirm the feasibility of minimal-access arytenoid adduction and abduction through development of a new technique and device.

Framework Surgery for Treatment of Unilateral Vocal Fold Paralysis

Laryngeal framework surgery is the current gold standard treatment for unilateral vocal fold paralysis. It provides a permanent solution to glottic insufficiency caused by injury to the recurrent laryngeal nerve. Various modifications to the original Isshiki type I laryngoplasty procedure have been described to improve voice and swallowing outcomes. The success of this procedure is highly dependent on the experience of the surgeon as it epitomizes the intersection of art and science in the field. The following article reviews the evidence, controversies, and complications related to laryngoplasty for unilateral vocal fold paralysis. It also provides a detailed analysis of how and when arytenoid-positioning procedures should be considered, and summarizes the literature on postoperative outcomes.

Phonological outcome of laryngeal framework surgery by different anesthesia protocols: a single-surgeon experience

CONCLUSION

Similar to combined arytenoid adduction and medialization laryngoplasty (i.e. combined surgery) under local anesthesia, general anesthesia by intubation or by the laryngeal mask airway (LMA) method significantly improves phonological outcome. Thus, laryngeal framework surgery under general anesthesia is a promising surgical approach for selected patients with unilateral vocal cord paralysis (UVCP).

OBJECTIVE

The advantages of laryngeal framework surgery under local anesthesia have been described, but no studies exist concerning the difference in phonological outcome of laryngeal framework surgery performed under general anesthesia. To add new information, we retrospectively investigated the phonological outcome of the combined surgery performed under three different anesthesia protocols.

METHODS

Thirty-nine consecutive patients with severe UVCP underwent the combined surgery under three anesthesia protocols performed by a single surgeon: (1) under general anesthesia by intubation, (2) under general anesthesia using LMA, and (3) under local anesthesia.

RESULTS

Under all anesthesia protocols, the vocal cords of most patients could be positioned such that the best vocal outcome could be expected. Statistical analyses demonstrated improved maximum phonation time and mean airflow rate, and grade, roughness, breathiness, asthenia, and strain (GRBAS) scale in all patients, regardless of their anesthesia protocol. Furthermore, of the three protocols, local anesthesia had the shortest operation time.

[Treatment of glottal gap]

Glottal gaps can be either physiological or pathological. The latter are multifactorial, predominantly organic in origin and occasionally functional. Organic causes include vocal fold paralysis or scarring, as well as a deficiency or excess of tissue. In addition to loss of the mucosal wave, the degree of hoarseness is primarily determined by the circumferential area of the glottal gap. It is thus important to quantify the extent of glottal insufficiency. Although a patient's symptoms form the basis for treatment decisions, these may be subjective and inadequately reflected by the results of auditory-perceptual evaluation, voice analysis and voice performance tests. The therapeutic approach should always combine phonosurgery with conventional voice therapy methods. Voice therapy utilises all the resources made available by the sphincter model of the aerodigestive tract and knowledge on the mechanism of voice production. The aim of phonosurgery is medialization, reconstruction or reinnervation by injection laryngoplasty or larynx framework surgery. These different methods can be combined and often applied directly after vocal fold surgery (primary reconstruction). In conclusion, the techniques described here can be effectively employed to compensate for glottal gaps.

Initial investigation of anterior approach to arytenoid adduction in excised larynges

OBJECTIVES/HYPOTHESIS

Arytenoid adduction (AA) can dramatically improve voice quality in patients with vocal fold paralysis (VFP); however, it is technically challenging. We present an anterior approach to AA, where GORE-TEX suture attached to curled wire is passed through the thyroid cartilage or cricothyroid membrane via a guide needle and used to manipulate the muscular process of the arytenoid. Performing AA via an anterior approach leads to comparable aerodynamic and acoustic outcomes compared to traditional AA in an excised larynx model.

STUDY DESIGN

Repeated measures with each larynx serving as its own control.

METHODS

We performed thyroplasty followed by traditional and anterior AA on excised larynges with simulated VFP. Aerodynamic and acoustic measurements were recorded.

RESULTS

Anterior AA significantly improved aerodynamic (phonation threshold power: P = .003) and acoustic parameters (percentage jitter: P = .028; percentage shimmer: P = .001; signal-to-noise ratio: P = .034) compared to VFP in this excised larynx model. Anterior AA and traditional AA produced comparable improvements in all parameters (phonation threshold power: P = .256; percentage jitter: P = .616; percentage shimmer: P = .281; signal-to-noise ratio: P = .970).

CONCLUSIONS

Anterior AA is an alternative to traditional AA that is easier to perform and produces comparable improvements in laryngeal function.

A Meta-analysis of Voice Outcome Comparing Calcium Hydroxylapatite Injection Laryngoplasty to Silicone Thyroplasty

Objectives

To compare the voice outcome of calcium hydroxylapatite (CaHA) injection laryngoplasty (IL) vs silicone medialization thyroplasty (MT) in the treatment of unilateral vocal fold paralysis (UVFP).

Data Sources

Systematic review of English literature from MEDLINE, Google Scholar, Web of Science, Scopus, and the Cochrane library from January 1, 1980, to December 31, 2010.

Review Methods

Included studies reporting voice-related quality of life (Voice Handicap Inventory [VHI]) following IL with CaHA or MT with silicone. The primary outcome measure was the improvement in VHI. The secondary outcome was improvement in maximum phonatory time (MPT).

Results

Of the 742 abstracts screened for relevancy, 24 studies qualified for analysis. The mean (SD) VHI scores were 72.22 (11.06) before MT and 34.02 (6.48) after MT. The mean (SD) VHI scores were 68.36 (6.88) before IL and 32.24 (7.33) after IL. The paired difference mean of VHI improvement was 38.20 (95% confidence interval [CI], 17.05-59.32; P = .007) for MT and 36.11 (95% CI, 29.65-42.57; P = .001) for IL. The mean (SD) MPT scores were 7.40 (3.14) before IL and 13.00 (1.75) after IL. The mean (SD) MPT scores were 6.16 (1.90) before MT and 12.40 (2.72) after MT. The paired difference mean of MPT improvement was 6.23 (95% CI, 4.74-7.73; P < .001) for MT and 5.60 (95% CI, 2.95-8.25; P = .006) for IL.

Conclusion

Injection laryngoplasty with CaHA and MT with silicone appear to achieve comparable voice improvement within 1 year, but a definitive conclusion is limited by a lack of standardized outcome measures.

Arytenoid adduction combined with medialization laryngoplasty under general anesthesia using a laryngeal mask airway

PURPOSE

Laryngeal framework surgery is usually performed under local anesthesia but cannot be tolerated by some patients. To develop a new procedure for these patients, we evaluated voice outcomes after arytenoid adduction combined with medialization laryngoplasty under general anesthesia using a laryngeal mask airway (LMA) for unilateral vocal cord paralysis.

MATERIALS AND METHODS

Eleven consecutive patients with severe unilateral vocal cord paralysis, with a maximum phonation time of less than 5 seconds, underwent arytenoid adduction combined with medialization laryngoplasty under general anesthesia using an LMA. Each paralyzed vocal cord was observed by intraoperative videolaryngoscopy. The vocal cord was moved to the position where the best vocal outcome could be expected, according to 3 parameters obtained from glottal images.

RESULTS

All patients achieved a maximum phonation time of more than 11 seconds. The mean airflow rate, which ranged from 550 to 1000 mL/s before surgery, improved to less than 390 mL/s. Perceptual evaluation using the grade, roughness, breathiness, asthenia and strain scale also improved significantly.

CONCLUSIONS

These results were equivalent to those of previous reports of surgeries performed under local anesthesia. Intraoperative endoscopic vocal cord observation through the LMA may have contributed to the positive results.

Medialization versus reinnervation for unilateral vocal fold paralysis: a multicenter randomized clinical trial

PURPOSE

Vocal fold medialization laryngoplasty (ML) and laryngeal reinnervation (LR) as treatments for unilateral vocal fold paralysis (UVFP) were compared in a multicenter, prospective, randomized clinical trial.

METHODS

Previously untreated patients with UVFP were randomized to undergo either ML or LR. Voice results were compared pretreatment and at 6 and 12 months posttreatment using perceptual ratings by untrained listeners (RUL), blinded speech pathologist GRBAS scores, and voice-related quality of life (VRQOL) scores. Other secondary data included maximum phonation time (MPT), cepstral analysis, and electromyography (EMG) findings.

RESULTS

Twenty-four patients from nine sites completed the study, 12 in each group. There were no significant intergroup differences in pretreatment variables. At 12 months, both study groups showed significant improvement in RUL, total GRBAS (grade, roughness, breathiness, asthenia, and strain) scores, and VRQOL scores, but no significant differences were found between the two groups. However, patient age significantly affected the LR, but not the ML, group results. The age less than 52 LR subgroup had significantly (P < .05) better scores than the age more than 52 LR subgroup, and had better RUL and GRBAS scores than the age less than 52 ML subgroup. The age more than 52 ML subgroup results were significantly better than the age more than 52 LR subgroup. The secondary data generally followed the primary data, except that the MPTs for the ML patients were significantly longer than for the LR patients.

CONCLUSIONS

ML and LR are both effective surgical options for patients with UVFP. Laryngeal reinnervation should be considered in younger patients, whereas medialization laryngoplasty should be favored in older patients.

Arytenoid rotation and nerve-muscle pedicle transfer in paralytic dysphonia

OBJECTIVES/HYPOTHESIS

Our objective was to evaluate the efficacy of modified nerve-muscle pedicle (NMP) flap transfer combined with arytenoid adduction (AA) (AA + modified NMP) for treatment of unilateral vocal fold paralysis. The patterns of voice outcome assessed using phonatory function tests and auditory perceptual judgments were followed-up for 2 years.

STUDY DESIGN

Prospective study.

METHODS

Thirteen subjects among those presented with paralytic dysphonia between March 2002 and December 2008 were treated with AA + modified NMP. The voice outcomes (six objective and two subjective voice parameters) were evaluated preoperatively and in four different time points postoperatively over 2-years duration.

RESULTS

All voice parameters showed initial postoperative improvement. Moreover, five parameters showed significant continuous improvement over the 2-year follow-up (maximum phonation time, pitch range, shimmer, and grade overall and breathiness of the grade-roughness-breathiness-asthenia-strain scale (GRBAS), whereas two parameters revealed continuous improvement over the first 12 to 14 months after surgery (mean flow rate and harmonics-to-noise ratio).

CONCLUSIONS

AA + modified NMP improves both short- and long-term voice outcomes in unilateral vocal fold paralysis patients. Therefore, AA + modified NMP is an effective surgical combination for the treatment of severe paralytic dysphonia.

Prospective multi-arm evaluation of surgical treatments for vocal fold scar and pathologic sulcus vocalis

OBJECTIVES/HYPOTHESIS

The purpose of this study was to compare the clinical effectiveness of type I thyroplasty, injection laryngoplasty, and graft implantation for the treatment of vocal fold scar and pathologic sulcus vocalis.

STUDY DESIGN

Prospective, multi-arm, quasi-experimental research design.

METHODS

Twenty-eight patients with newly diagnosed vocal fold scar and/or pathologic sulcus vocalis were assigned to one of three treatment modalities: type I thyroplasty (n = 9), injection laryngoplasty (n = 9), and graft implantation (n = 10). Psychosocial, auditory-perceptual, acoustic, aerodynamic, and videostroboscopic data were collected pretreatment and at 1, 6, 12, and 18 months posttreatment.

RESULTS

Type I thyroplasty and graft implantation both resulted in reduced voice handicap with no concomitant improvement in auditory-perceptual, acoustic, aerodynamic, or vocal fold physiologic performance. Injection laryngoplasty resulted in no improvement on any vocal function index. Patients who underwent graft implantation exhibited the slowest improvement trajectory across the 18-month follow-up period.

CONCLUSIONS

A persistent challenge in this area is that no single treatment modality is successful for the majority of patients, and there is no evidence-based decision algorithm for matching a given treatment to a given patient. Progress therefore requires the identification and categorization of predictive clinical features that can drive evidence-based treatment assignment.