A new paramedian approach to arytenoid adduction and strap muscle transposition for vocal fold medialization

Outcomes in two patients with vocal fold palsy who underwent revision arytenoid adduction surgery

Objective

This study investigated the position of adduction thread attachment, pulling direction and fixation position in revision arytenoid adduction surgery performed in two patients with left vocal fold palsy in whom satisfactory speech improvement had not been obtained by arytenoid adduction and type 1 thyroplasty.

Methods

Revision arytenoid adduction surgery was performed with the vocal fold in the midline position in both cases. A type 1 thyroplasty procedure was subsequently added in one case because of worsened quality of speech following arytenoid adduction.

Results and conclusion

Although the arytenoid adduction procedure is conceptually well established, there is still room for debate concerning the actual surgical procedures used. The technique described in this report is effective, suggesting that it is worthy of recognition as an index procedure.

Autologous thyroid cartilage graft implantation in medialization laryngoplasty: a modified approach for treating unilateral vocal fold paralysis

Medialization laryngoplasty is the standard surgical treatment for unilateral vocal fold paralysis. This study presents a modified approach in which a thyroid cartilage graft is implanted in medialization laryngoplasty. 22 patients who underwent this approach were included in the study. The results revealed that glottal incompetence and vocal performance were markedly improved following surgery, and the follow-up period ranged from 6 to 74 months (mean, 21.4 months). Acoustic analysis revealed significant improvements in the maximum phonation time (from 3.51 to 7.89 seconds, p < 0.001), F0 (from 221.7 to 171.0 Hertz, p = 0.025), and jitter (from 7.68 to 3.19, p < 0.001). Perceptual assessment revealed a significant decrease in voice grading (from 2.59 to 1.41, p < 0.001), roughness (from 1.82 to 1.23, p = 0.004), and voice breathiness (from 2.55 to 1.23, p < 0.001). None of the patients exhibited severe wound infection, tissue rejection, or other complications attributed to the surgical procedure. In conclusion, autologous thyroid cartilage implantation in medialization laryngoplasty medializes the vocal cord, minimizes the glottal gap, and improves the voice of patients with vocal fold paralysis. This procedure is characterized by simplicity, safety, and acceptable results.

Endoscopic Laser Anterior Commissurotomy for Anterior Glottic Web: One-Stage Procedure

Objectives

The conventional method for preventing web formation after anterior glottic web surgery is keel insertion. However, this presents risks of airway compromise and granulation tissue formation, which could necessitate tracheotomy in addition to a secondary procedure for keel removal. We introduce a novel, 1-stage endoscopic laser anterior commissurotomy for preventing anterior glottic web re-formation.

Methods

Twenty patients with glottic webs involving the anterior commissure were studied. The lesions were removed by transoral carbon dioxide laser microsurgery. In all patients, the anterior glottic web was vaporized along with the inner perichondrium of the thyroid cartilage over the anterior commissure area, creating a raw vertical break “alley” between the anterior vocal folds that measured between 0.3 and 0.5 cm in width and between 0.8 and 2 cm in length. The preoperative and postoperative vocal folds and voice quality were evaluated by videostrobolaryngoscopy and voice recordings.

Results

All 20 patients had anterior glottic webs ranging from 11 % to 64% of the length from the anterior commissure to the vocal process. None of the patients developed restenosis at the anterior commissure of a severity similar to that of the initial lesion during follow-up (mean, 13 months; range, 3 to 44 months). All patients except 1 reported satisfaction with their voice improvement. Outcome analysis revealed that partial re-formation of the web was noted in 4 patients.

Conclusions

One-stage, endoscopic laser anterior commissurotomy was effective and relatively safe for removing glottic webs, for preventing anterior glottic web re-formation, and for improving vocal fold performance among our patients.

Transoral Approach to Laser Thyroarytenoid Myoneurectomy for Treatment of Adductor Spasmodic Dysphonia: Short-Term Results

Objectives:

The surgical technique for the resection of the recurrent laryngeal nerve for adductor spasmodic dysphonia (ASD) has high late failure rates. During the past decade, botulinum toxin has emerged as the treatment of choice for ASD. Although effective, it also has significant disadvantages, including a temporary effect and an unpredictable dose-response relationship. In this study we investigated the effectiveness of a new transoral approach to laser thyroarytenoid myoneurectomy for treatment of ASD.

Methods:

Fourteen patients with ASD underwent transoral laser myoneurectomy of bilateral thyroarytenoid muscles. Under general anesthesia, an operating microscope and a carbon dioxide laser were used to perform myectomy of the mid-posterior belly of bilateral thyroarytenoid muscles together with neurectomy of the terminal nerve fibers among the deep muscle bundles. Care was taken not to damage the vocalis ligaments, arytenoid cartilages, and lateral cricoarytenoid muscles. Preoperative and postoperative videolaryngostroboscopy and vocal assessments were studied.

Results:

The 13 patients who completed more than 6 months follow-up were enrolled in this study. Moderate and marked vocal improvement was achieved in 92% of the patients (12 of 13) after laser surgery during an average follow-up period of 17 months (range, 6 to 31 months). No vocal fold atrophy or paralysis was observed in any patient. None of the patients had a recurrence during the follow-up period.

Conclusions:

Transoral laser myoneurectomy of bilateral thyroarytenoid muscles is a relatively simple, effective, and valuable technique for the treatment of ASD. The durability of outcome achieved with this procedure is encouraging.

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.

Endoscopic laser thyroarytenoid myoneurectomy in patients with adductor spasmodic dysphonia: a pilot study on long-term outcome on voice quality

OBJECTIVES

Adductor spasmodic dysphonia (ADSD) is a focal laryngeal dystonia, which compromises greatly the quality of life of the patients involved. It is a severe vocal disorder characterized by spasms of laryngeal muscles during speech, producing phonatory breaks, forced, strained and strangled voice. Its symptoms result from involuntary and intermittent contractions of thyroarytenoid muscle during speech, which causes vocal fold to strain, pressing each vocal fold against the other and increasing glottic resistance. Botulinum toxin injection remains the gold-standard treatment. However, as injections should be repeated periodically leading to voice quality instability, a more definitive procedure would be desirable. In this pilot study we report the long-term vocal quality results of endoscopic laser thyroarytenoid myoneurectomy.

STUDY DESIGN

Prospective study.

METHODS

Surgery was performed in 15 patients (11 females and four males), aged between 29 and 73 years, diagnosed with ADSD. Voice Handicap Index (VHI) was obtained before and after surgery (median 31 months postoperatively).

RESULTS

A significant improvement in VHI was observed after surgery, as compared with baseline values (P=0.001). The median and interquartile range for preoperative VHI was 99 and 13, respectively and 24 and 42, for postoperative VHI. Subjective improvement of voice as assessed by the patients showed median improvement of 80%.

CONCLUSIONS

Because long-term follow-up showed significant improvement of voice quality, this innovative surgical technique seems a satisfactory alternative treatment of ADSD patients who seek a definite improvement of their condition.

Optimal arytenoid adduction based on quantitative real-time voice analysis

HYPOTHESIS

The optimal degree of arytenoid rotation for arytenoid adduction (AA) can be determined using quantitative real-time voice analysis.

STUDY DESIGN

Repeated measures with each larynx serving as its own control.

METHODS

Unilateral vocal fold paralysis (VFP) was modeled in five excised canine larynges. Medialization laryngoplasty (ML) was performed, followed by AA. The optimal degree of arytenoid rotation was determined using real-time measurements of vocal efficiency (V(E) ), percent jitter, and percent shimmer. After the optimal degree of rotation was determined, the arytenoid was hypo- and hyperrotated 10% ± 2% of the optimal angle to mimic hypoadducted and hyperadducted states. Aerodynamic, acoustic, and mucosal wave measurements were recorded.

RESULTS

Mean optimal angle of arytenoid adduction was 151.4 ± 2.5°. V(E) differed significantly across experimental conditions (P = .003). Optimal AA produced the highest V(E) of any treatment, but this value did not reach that produced in the normal condition. Percent jitter (P < .001) and percent shimmer (P < .001) differed across groups and were lowest for optimal AA. Mucosal wave amplitude of the normal (P = .001) and paralyzed fold (P = .043) differed across treatments. Amplitude of both folds was highest for optimal AA.

CONCLUSIONS

V(E) and perturbation parameters were sensitive to the degree of arytenoid rotation. Using real-time voice analysis may aid surgeons in determining the optimal degree of arytenoid rotation when performing AA. Testing this method in patients and determining if optimal vocal outcomes are associated with optimal respiratory and swallowing outcomes will be essential to establishing clinical viability.

Modified arytenoid adduction for cancer-related unilateral vocal fold paralysis

OBJECTIVES

(1) To evaluate the efficacy of modified arytenoid adduction in the management of patients with symptomatic cancer-related unilateral vocal fold paralysis, and (2) to assess the impact of this treatment on patients' quality of life.

METHODS

Forty-two patients with cancer-related unilateral vocal fold paralysis underwent modified arytenoid adduction between February 2001 and December 2008. Of these, 37 patients were enrolled in this retrospective study (one patient died of primary disease and four were lost to follow up). Laryngostroboscopy was performed to evaluate vocal fold orientation and mobility. Pre- and post-operative assessment of subjective and objective voice, aerodynamic parameters, and quality of life were also undertaken, and aspiration was subjectively rated.

RESULTS

Laryngostroboscopic findings indicated a significant post-operative improvement in vocal fold posterior glottal closure and vertical gap. Significant improvements in voice quality, aerodynamic parameters and quality of life were noted three months post-operatively in all patients (p < 0.01). The overall success rate for swallowing rehabilitation was 94.6 per cent (35/37). Subjective aspiration ratings decreased significantly post-operatively, compared with pre-operative values (p < 0.01). No major complication occurred in any patient, except for dyspnoea in one patient.

CONCLUSION

Modified arytenoid adduction is an effective and reliable medialisation technique which can restore satisfactory voice quality, prevent aspiration and lead to a better quality of life for patients with cancer-related unilateral vocal fold paralysis.

Multiparameter comparison of injection laryngoplasty, medialization laryngoplasty, and arytenoid adduction in an excised larynx model

OBJECTIVES/HYPOTHESIS

Evaluate the effect of injection laryngoplasty (IL), medialization laryngoplasty (ML), and ML combined with arytenoid adduction (ML-AA) on acoustic, aerodynamic, and mucosal wave measurements in an excised larynx setup.

STUDY DESIGN

Comparative case study using ex vivo canine larynges.

METHODS

Measurements were recorded for eight excised canine larynges with simulated unilateral vocal fold paralysis before and after vocal fold injection with Cymetra. A second set of eight larynges was used to evaluate medialization laryngoplasty using a Silastic implant without and with arytenoid adduction.

RESULTS

IL and ML led to comparable decreases in phonation threshold flow (PTF), phonation threshold pressure (PTP), and phonation threshold power (PTW). ML-AA led to significant decreases in PTF (P = .008), PTP (P = .008), and PTW (P = .008). IL and ML led to approximately equal decreases in percent jitter and percent shimmer. ML-AA caused the greatest increase in signal-to-noise ratio. ML-AA discernibly decreased frequency (P = 0.059); a clear trend was not observed for IL or ML. IL significantly reduced mucosal wave amplitude (P = 0.002), whereas both ML and ML-AA increased it. All procedures significantly decreased glottal gap, with the most dramatic effects observed after ML-AA (P = 0.004).

CONCLUSIONS

ML-AA led to the greatest improvements in phonatory parameters. IL was comparable to ML aerodynamically and acoustically, but caused detrimental changes to the mucosal wave. Incremental improvements in parameters recorded from the same larynx were observed after ML and ML-AA. To ensure optimal acoustic outcome, the arytenoid must be correctly rotated. This study provides objective support for the combined ML-AA procedure in tolerant patients.

Transoral laser ventricular fold resection and thyroarytenoid myoneurectomy for adductor spasmodic dysphonia: long-term outcome

OBJECTIVES

A transoral approach to laser myoneurectomy of the thyroarytenoid muscles was recently reported as an effective technique for treatment of adductor spasmodic dysphonia (ASD). The short-term results were encouraging. In this study, a long-term surgical outcome of this technique is investigated.

STUDY DESIGN

A prospective clinical series.

METHODS

Fifty-two patients with ASD underwent transoral laryngomicrosurgery with a CO(2) laser to resect the ventricular folds followed by myoneurectomy of the thyroarytenoid muscles. The nerve fibers of recurrent laryngeal nerve terminating at the thyroarytenoid muscle, which were frequently found branching deeply among the posterior belly of this muscle, were vaporized. Care was taken not to damage the vocal ligaments, lateral cricoarytenoid muscles, or arytenoid cartilages. Pre- and postoperative subjective voice assessments, and acoustic and aerodynamic measurements, were performed and statistically analyzed.

RESULTS

Twenty-nine of the 52 patients who were followed up for more than 12 months (range, 12-63 months; mean, 31 months) were studied. Moderate and marked vocal improvement was achieved in 90% (26/29) of the patients. Three patients had 30% improvement, which was reported as unsuccessful. Eight of the 26 patients who were satisfied with their postoperative voice still had a mild strain during phonation. Of the eight patients, seven achieved normal or nearly normal voice quality after revision laser surgery. No significant vocal deficit or paralysis was observed in any patient.

CONCLUSIONS

After long-term follow-up of 31 months on average, approximately 90% of the ASD patients obtained moderate to marked improvement of vocal performance after transoral laser surgery. The long-lasting outcome is encouraging.

Marsupialisation and strap muscle transposition laryngoplasty for vocal cysts with vocal fold atrophy

Objectives:

Vocal cysts with fold atrophy often result in more severe glottal incompetence than vocal cysts along during phonation. Although total excision or marsupialisation are reliable treatments for vocal fold cysts, any post-operative vocal deficit with significant glottal gap will need further treatment. This study aimed to evaluate the efficacy of combined treatment consisting of marsupialisation of the cyst immediately followed by strap muscle transposition laryngoplasty.

Method:

Under direct laryngomicroscopy, microscissors were used to make a disc-shaped incision encircling the equator of the cyst. After marsupialisation of the cyst, a simultaneous medialisation laryngoplasty with strap muscle transposition was performed.

Results:

Seven patients with vocal cysts and marked vocal fold atrophy were included in the study. After surgery, subjective improvement in voice quality was reported by all patients. Patients' glottal incompetence and vocal performance were markedly improved.

Conclusion:

Marsupialisation is a simple and effective surgical technique for vocal fold cysts. For cases of vocal cysts with marked vocal fold atrophy, marsupialisation followed by medialisation laryngoplasty with strap muscle transposition may be considered.

Marsupialization of Vocal Fold Retention Cysts: Voice Assessment and Surgical Outcomes

Objectives:

Although total excision remains the standard treatment for vocal fold retention cysts, postoperative deficits and damage to the vocal folds still occur. Marsupialization is a more conservative technique and can prevent these complications.

Methods:

In this prospective clinical series, 25 patients underwent the marsupialization procedure. Under a direct laryngomicroscope, the cystic wall margin was retracted medially with microforceps. An incision was made with microscissors encircling the equator of the cyst. The cyst contents drained from the cystic cavity when the capsule was sectioned. For 7 patients with concomitant marked vocal fold atrophy, strap muscle transposition laryngoplasty was simultaneously performed.

Results:

All patients had complete preoperative and postoperative voice parameter analyses. A subjective improvement in voice quality was reported by 23 of the 25 patients (92%). A small recurrent vocal fold cyst was detected in 1 patient. Small vocal fold deficits and sulcus vocalis were detected in 2 and 4 patients, respectively. Only 1 patient described a worse voice after operation. No other complications were noted.

Conclusions:

Marsupialization of vocal fold retention cysts is a simple, relatively safe, and effective surgical treatment. Voice improvement, a low incidence of recurrence, and minimal vocal fold deficits demonstrate the validity of this technique. Marked preoperative vocal fold atrophy or postoperative glottal gap can be managed with medialization laryngoplasty.

Impact in vocal quality in partial myectomy and neurectomy endoscopic of thyroarytenoid muscle in patients with adductor spasmodic dysphonia

Impact in vocal quality in partial myectomy and neurectomy endoscopic of thyroarytenoid muscle in patients with adductor spasmodic dysphonia the adductor spasmodic dysphonia is a severe vocal disorder characterized by muscle laryngeal spasms during speech, producing phonatory breaks, forced, strained and strangled voice. Its symptoms come from involuntary and intermittent contractions of thyroarytenoid muscle during speech, which causes vocal fold strain, pressed one against another and increased glottic resistance. Aim: report the results in the impact in vocal quality in neurectomy of the thyroarytenoid branch of the inferior laryngeal nerve by endoscopic route associated with partial myectomy of the thyroarytenoid muscle with co2 laser. Material and method: the surgery was done in 07 patients (06 females and 01 male), aged 22 to 75, with adductor spasmodic dysphonia. They were submitted to vhi (voice handicap index) before and after surgery. Results and conclusions: the vocal improvement was obtained in all studied patients, deterioration in vocal quality after surgery was not noticed. There was evident difference in the vhi before and after surgery. This surgical thecnique proved to be efficient and innovative in the treatment of adductor spasmodic dysphonia.

Unilateral arytenoid adduction improves voice in a patient with bilateral vocal fold immobility

Bilateral vocal fold immobility (BVFI) due to prolonged endotracheal intubation resulted in aphonia without any airway morbidity and was treated by several reconstructive procedures. Laryngeal reinnervation and silicone implantation failed to medialize one of those two fixed cords. Arytenoid adduction (AA) eventually achieved this goal. To select an optimal reconstructive procedure, a careful perusal of the history and head and neck examination including laryngeal electromyography, are necessary to determine the causes. AA procedure played an essential clinical indication in this study, not just an adjunct to the medialization laryngoplasty as usual. Since both the vocal cords positions were ranked as lateral positions subjectively, the full adduction for one of those two fixed vocal cords was performed without significant airway obstruction. The practice in this study provided an experience in correcting the voice in patients with BVFI. We need further experience to medialize the vocal cord in an appropriate magnitude since its counterpart may position variously and compromise the airway.

Functional Significance of Arytenoid Adduction with the Suture Attaching to Cricoid Cartilage versus to Thyroid Cartilage for Unilateral Paralytic Dysphonia

OBJECTIVE

In the treatment of unilateral paralytic dysphonia, traditional arytenoid adduction is designed to place suture through the muscular process of the arytenoid attaching anteriorly to the thyroid ala. In contrast with the suture direction of this technique, a new paramedian approach to arytenoid adduction anchors anteroinferiorly to the cricoid cartilage, mimicking the force action of the lateral cricoarytenoid muscle (the major adductor of the larynx). This study investigated the influence of these changes in suture direction on the vocal fold level as well as the vocal outcomes in these two techniques of arytenoid adduction.

STUDY DESIGN

A prospective clinical series.

METHODS

Thirty patients with unilateral paralytic dysphonia underwent medialization laryngoplasty with arytenoid adduction and strap muscle transposition. Under local anesthesia, the thyroid lamina on the involved side was paramedially separated. The inner perichondrium was carefully elevated away from the overlying thyroid cartilage, carrying the dissection posteriorly to the level of the superior and inferior cornua. The lamina was retracted laterally, the inner perichondrium was opened near the midpoint, and the lateral cricoarytenoid muscle identified. Tracing the muscle fibers posterosuperiorly, the muscular process of the arytenoid was identified. A 2-0 Prolene suture was placed through the muscular process and temporarily tied to the anterolateral aspect of the thyroid ala (AA-thyroid suture). Intraoperative acoustic and perceptual assessments were performed. After releasing the tie, the suture was anchored to the cricoid cartilage at the origin of the lateral cricoarytenoid muscle (AA-cricoid suture). Voice assessments were repeated, and the outcomes of the two tests were compared. The choice of the type of arytenoid adduction suture was made intraoperatively according to which condition provided better vocal performance. After securing the suture, a bipedicled strap muscle flap was transposed into the space between the lamina and inner perichondrium and the thyroid cartilages sutured back into place.

RESULTS

The intraoperative acoustic and perceptual assessments revealed the vocal performance was significantly better with AA-cricoid suture than the AA-thyroid suture in this series. No major complications occurred in the study.

CONCLUSION

This study suggests that arytenoid adduction with suture attachment along the longitudinal axis of the lateral cricoarytenoid muscle to the cricoid cartilage is more physiologic and effective than that attaching the suture to the thyroid ala. A paramedian approach to arytenoid adduction with or without strap muscle transposition is a safe and effective method for treatment of unilateral paralytic dysphonia.

Perception of aperiodicity in pathological voice

Although jitter, shimmer, and noise acoustically characterize all voice signals, their perceptual importance in naturally produced pathological voices has not been established psychoacoustically. To determine the role of these attributes in the perception of vocal quality, listeners were asked to adjust levels of jitter, shimmer, and the noise-to-signal ratio in a speech synthesizer, so that synthetic voices matched naturally produced tokens. Results showed that, although listeners agreed well in their judgments of the noise-to-signal ratio, they did not agree with one another in their chosen settings for jitter and shimmer. Noise-dependent differences in listeners' ability to detect changes in amounts of jitter and shimmer implicate both listener insensitivity and inability to isolate jitter and shimmer as separate dimensions in the overall pattern of aperiodicity in a voice as causes of this poor agreement. These results suggest that jitter and shimmer are not useful as independent indices of perceived vocal quality, apart from their acoustic contributions to the overall pattern of spectrally shaped noise in a voice.

Bipedicled Strap Muscle Transposition for Vocal Fold Deficit after Laser Cordectomy in Early Glottic Cancer Patients

OBJECTIVE

In treating early glottic carcinomas, the outcomes of endoscopic laser cordectomy have been proven to be valuable in local control, survival, and vocal function preservation. In some extended cases, however, laser cordectomy may leave patients with poor vocal function because of vocal fold deficit. This work assesses the vocal outcome of medialization laryngoplasty with bipedicled strap muscle transposition for vocal fold deficit resulting from laser cordectomy in early glottic cancer patients.

STUDY DESIGN

A prospective clinical series.

METHODS

Thirteen early glottic cancer patients who had vocal fold deficit caused by previous laser cordectomy underwent medialization laryngoplasty with bipedicled strap muscle transposition. The thyroid lamina on the cordectomy side was paramedially separated. The inner perichondrium was circumspectly raised from the overlying thyroid cartilage. After separating the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally. A bipedicled strap muscle flap was then transposed into the area between the lamina and the paraglottic soft tissue. The thyroid cartilages were carefully sutured back in position. All patients received pre- and postoperative voice assessments comprising laryngostroboscopy and vocal function studies.

RESULTS

Vocal enhancement was present in 92% (12/13) of patients after medialization laryngoplasty with strap muscle transposition. The glottal closure and maximal phonation time were noticeably improved by surgery. No dyspnea or other significant complications were observed in any patients.

CONCLUSION

The outcomes show that bipedicled strap muscle transposition is a prosthesis-free, safe, and valuable laryngoplastic technique for correcting glottal incompetence caused by endoscopic laser cordectomy in early glottic cancer patients.

Prediction of Laryngeal Aspiration Using Voice Analysis

OBJECTIVE

To determine the diagnostic value of voice analysis to screen for patients with high risk of clinically significant aspiration.

DESIGN

A total of 93 patients referred for a videofluoroscopic swallowing study were included in the study. Voice analyses were performed before and after videofluoroscopic swallowing study, and five acoustic variables were measured, including average fundamental frequency, relative average perturbation, shimmer percentage, noise-to-harmonic ratio, and voice turbulence index. The patients were divided into two groups based on the results of the videofluoroscopic swallowing study: a high-risk group with patients who had the ingested materials on or below the vocal cords and a low-risk group with patients who did not have the ingested materials on or below the vocal cords. The changes of each acoustic variable before and after the videofluoroscopic swallowing study were compared between the two groups.

RESULTS

Relative average perturbation, shimmer percentage, noise-to-harmonic ratio, and voice turbulence index were significantly increased after videofluoroscopic swallowing study in the high-risk group as compared with the low-risk group (P < 0.05). The change of average fundamental frequency, however, was not significantly different between the two groups (P > 0.05). According to the receiver operating characteristics curve, the sensitivity of these acoustic variables in detecting aspiration or penetration ranged from 68.9% to 91.1% and specificity ranged from 68.8% to 97.9%. Relative average perturbation was the most accurate variable, with a sensitivity of 91.1% and a specificity of 97.9% in predicting aspiration or penetration. The combination of relative average perturbation and noise-to-harmonic ratio increased the sensitivity to 100% but reduced the specificity to 77.1%.

CONCLUSION

Voice analysis is a safe, noninvasive, and reliable screening tool for patients with dysphagia and can detect patients at high risk of clinically significant aspiration, thereby augmenting clinical bedside examination.

Lateral thyrotomy with strap muscle transposition for Teflon granuloma

Lateral thyrotomy and strap muscle transposition have been used independently before. However, the published literature does not record the coordinated use of both procedures in the treatment of Teflon granuloma. In this paper, we present a case of vocal fold paralysis that had been treated successfully by Teflon injection in 1999. Two years later, however, the patient developed a host of symptoms that included a husky voice, shortness of breath and suffocation, which indicated Teflon granuloma. He underwent surgery to excise the Teflon granuloma via a lateral thyrotomy. The affected paraglottic space was then reconstructed using strap muscle transposition. One year postoperatively, the glottis had closed completely on phonation, and the voice retained a moderate roughness due to a scarring change from the earlier Teflon reaction. The patient had no problems with aspiration or shortness of breath during speaking. Our experience indicates that a physician can remove the entire granuloma and create a smooth, straight vibratory surface with complete glottic closure during phonation by using a combination of lateral thyrotomy and strap muscle transposition.

Medialization Laryngoplasty With Strap Muscle Transposition for Vocal Fold Atrophy with or without Sulcus Vocalis

OBJECTIVE

Vocal fold atrophy with or without sulcus vocalis may result in a spindle-shaped glottal incompetence (SGI). Because of varying drawbacks with all existing materials (e.g., Silastic block, Teflon, fat, etc.) used for medialization or augmentation of the atrophic vocal folds, there is a need to supplant these materials with a more stable, autologous tissue to correct the SGI.

STUDY DESIGN

Thirty-two patients with vocal fold atrophy underwent medialization laryngoplasty with strap muscle transposition.

METHODS

Under local or general anesthesia, the thyroid lamina on the more affected side was vertically incised 5 mm off the midline. The inner perichondrium was carefully elevated from the overlying thyroid ala. Care was taken not to enter the laryngeal lumen. After dividing the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally. To accommodate the muscle flap more easily, the caudal edge of the lamina was trimmed using a small burr. A bipedicled strap muscle flap was then transposed into the space between the lamina and the paraglottic soft tissue. The thyroid cartilages were carefully sutured back in place. All patients underwent pre- and postoperative voice evaluations including laryngostroboscopy, perceptual assessment, and acoustic and aerodynamic analyses. Patients who had been followed up for more than 3 months were enrolled in this study.

RESULTS

A total of 27 of the 32 patients with complete pre- and postoperative voice function measurements were included in the analysis. Vocal improvement was demonstrated in 26 of these 27 (96%) patients. No dyspnea or other major complications were noted in any patients.

CONCLUSION

The results indicate that medialization laryngoplasty with strap muscle transposition is a prosthesis-free, safe, and effective technique for correcting SGI caused by vocal fold atrophy.

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

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

Neurorrhaphy of the recurrent laryngeal nerve

BACKGROUND

It has been controversial to anastomose the severed recurrent laryngeal nerve after transection because when severed recurrent nerves are directly anastomosed, the vocal cords do not regain normal movements and are fixed in the median. The objective of this study was to learn whether direct neurorrhaphy is necessary if the recurrent laryngeal nerve is severed during thyroid or parathyroid surgery.

STUDY DESIGN

From 1998 to 2001, 12 patients who had a complete recurrent laryngeal nerve injury during thyroid or parathyroid surgery were enrolled into this study. Eight had primary repair of the nerve; four did not have repair because of cancer invasion. Patients were followed with laryngoscopic or laryngovideostroboscopic examination at 3 months and 6 months postoperatively. Subjective ratings of aspiration and voice quality were based on patient reports. Perceptual voice quality was rated according to grade, roughness, breathiness, asthenia, and strain (GRBAS) scales. If a patient's voice quality, aspiration, and GRBAS scales did not improve at 6 months postoperatively, medialization laryngoplasty was considered.

RESULTS

Eight patients with immediate repair showed improved voice quality, aspiration, GRBAS scales, and maximum phonation time at 6 months after surgery. A significant decrease of glottal gap was also noted in patients with neurorrhaphy but not in four patients without neurorrhaphy. Medialization laryngoplasty was performed in all four patients without neurorrhaphy in the followup period. Immobilization of the vocal cord was noted in all of them, but only one in the neurorrhaphy group had an atrophy of the cord; all four patients without neurorrhaphy had atrophy.

CONCLUSIONS

Neurorrhaphy of the recurrent laryngeal nerve is a simple and effective procedure to improve voice quality, aspiration, GRBAS scales, glottal gap, and maximum phonation time by preventing atrophy of the vocal cord.