Functional results after external vocal fold medialization thyroplasty with the titanium vocal fold medialization implant

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.

Simultaneous High-Speed Video Laryngoscopy and Acoustic Aerodynamic Recordings during Vocal Onset of Variable Sound Pressure Level: A Preliminary Study

Voicing: requires frequent starts and stops at various sound pressure levels (SPL) and frequencies. Prior investigations using rigid laryngoscopy with oral endoscopy have shown variations in the duration of the vibration delay between normal and abnormal subjects. However, these studies were not physiological because the larynx was viewed using rigid endoscopes. We adapted a method to perform to perform simultaneous high-speed naso-endoscopic video while simultaneously acquiring the sound pressure, fundamental frequency, airflow rate, and subglottic pressure. This study aimed to investigate voice onset patterns in normophonic males and females during the onset of variable SPL and correlate them with acoustic and aerodynamic data.

MATERIALS AND METHODS

Three healthy males and three healthy females were studied by simultaneous high-speed video laryngoscopy and recording with the production of the gesture [pa:pa:] at soft, medium, and loud voices. The fiber optic endoscope was threaded through a pneumotachograph mask for the simultaneous recording and analysis of acoustic and aerodynamic data.

RESULTS

The average increase in the sound pressure level (SPL) for the group was 15 dB, from 70 to 85 dB. The fundamental frequency increased by an average of 10 Hz. The flow was increased in two subjects, reduced in two subjects, and remained the same in two subjects as the SPL increased. There was a steady increase in the subglottic pressure from soft to loud phonation. Compared to soft to medium phonation, a significant increase in glottal resistance was observed with medium-to-loud phonation. Videokymogram analysis showed the onset of vibration for all voiced tokens without the need for full glottis closure. In loud phonation, there is a more rapid onset of a larger amplitude and prolonged closure of the glottal cycle; however, more cycles are required to achieve the intended SPL. There was a prolonged closed phase during loud phonation. Fast Fourier transform (FFT) analysis of the kymography waveform signal showed a more significant second- and third-harmonic energy above the fundamental frequency with loud phonation. There was an increase in the adjustments in the pharynx with the base of the tongue tilting, shortening of the vocal folds, and pharyngeal constriction.

CONCLUSION

Voice onset occurs in all modalities, without the need for full glottal closure. There was a more significant increase in glottal resistance with loud phonation than that with soft or middle phonation. Vibration analysis of the voice onset showed that more time was required during loud phonation before the oscillation stabilized to a steady state. With increasing SPL, there were significant variations in vocal tract adjustments. The most apparent change was the increase in tongue tension with posterior displacement of the epiglottis. There was an increase in pre-phonation time during loud phonation. Patterns of muscle tension dysphonia with laryngeal squeezing, shortening of the vocal folds, and epiglottis tilting with increasing loudness are features of loud phonation. These observations show that flexible high-speed video laryngoscopy can reveal observations that cannot be observed with rigid video laryngoscopy. An objective analysis of the digital kymography signal can be conducted in selected cases.

Vocal fold restoration after scarring: biocompatibility and efficacy of an MSC-based bioequivalent

BACKGROUND

There is growing interest to application of regenerative medicine approaches in otorhinolaryngological practice, especially in the framework of the therapy of vocal fold (VF) scar lesions. The used conservative and surgical methods, despite the achieved positive outcomes, are frequently unpredictable and do not result in the restoration of the VF's lamina propria's structure, which provides the mechanical properties necessary for vibration. In this connection, the aim of this study was to ascertain the safety and efficacy of a bioequivalent in the treatment of VF scars using a rabbit model of chronic damage.

METHODS

The bioequivalent consisted of a hydrogel system based on a PEG-fibrin conjugate and human bone marrow-derived MSC. It was characterized and implanted heterotopically into rats and orthotopically into rabbits after VF scar excision.

RESULTS

We showed that the fabricated bioequivalent consisted of viable cells retaining their metabolic and proliferative activity. While being implanted heterotopically, it had induced the low inflammatory reaction in 7 days and was well tolerated. The orthotopic implantation showed that the gel application was characterized by a lower hemorrhage intensity (p = 0.03945). The intensity of stridor and respiratory rate between the groups in total and between separate groups had no statistically significant difference (p = 0.96 and p = 1; p = 0.9593 and p = 0.97…1, respectively). In 3 days post-implantation, MSC were detected only in the tissues closely surrounding the VF defect. The bioequivalent injection caused that the scar collagen fibers were packed looser and more frequently mutually parallel that is inherent in the native tissue (p = 0.018). In all experimental groups, the fibrous tissue's ingrowth in the adjacent exterior muscle tissue was observed; however, in Group 4 (PEG-Fibrin + MSC), it was much less pronounced than it was in Group 1 (normal saline) (p = 0.008). The difference between the thicknesses of the lamina propria in the control group and in Group 4 was not revealed to be statistically significant (p = 0.995). The Young's modulus of the VF after the bioequivalent implantation (1.15 ± 0.25 kPa) did not statistically significantly differ from the intact VF modulus (1.17 ± 0.45 kPa); therefore, the tissue properties in this group more closely resembled the intact VF.

CONCLUSIONS

The developed bioequivalent showed to be biocompatible and highly efficient in the restoration of VF's tissue.

Effects of implant and vocal fold stiffness on voice production after medialization laryngoplasty in an MRI-based vocal fold model

Medialization laryngoplasty is one of the primary surgical interventions in the treatment of glottal insufficiency due to vocal fold paralysis, paresis, or atrophy. During the surgery, an implant is laterally inserted into the larynx to medialize the affected vocal fold toward glottal midline, with the goal of improving glottal closure during phonation and voice production efficiency. While implants of different materials and geometry designs have been used, the effect of implant design on the voice outcome remains unclear. In this simulation study, the effect of implant stiffness was investigated in an MRI-based model of the vocal folds after medialization laryngoplasty. The results showed that implant stiffness had a significant impact on the phonation threshold pressure, glottal area waveform, and fundamental frequency, but only small effect on the closed quotient and other acoustic measures of the produced voice. The effect of implant stiffness also exhibited variability, depending on the stiffness conditions of the vocal fold and paraglottic tissues, indicating that individual differences need to be considered during the planning of medialization laryngoplasty.

Dysphagia Outcomes Following Surgical Management of Unilateral Vocal Fold Immobility: A Systematic Review and Meta-analysis

OBJECTIVE

To assess dysphagia outcomes following surgical management of unilateral vocal fold immobility (UVFI) in adults.

DATA SOURCES

Ovid MEDLINE, Embase, Web of Science, and Cochrane Central.

REVIEW METHODS

A structured literature search was utilized, and a 2-researcher systematic review was performed following PRISMA guidelines. Extractable data were pooled, and a quantitative analysis was performed with a random effects model to analyze treatment outcome and complications by procedure.

RESULTS

A total of 416 publications were screened and 26 met inclusion criteria. Subjects encompassed 959 patients with UVFI who underwent 916 procedures (n = 547, injection laryngoplasty; n = 357, laryngeal framework surgery; n = 12, laryngeal reinnervation). An overall 615 were identified as having dysphagia as a result of UVFI and had individually extractable outcome data, which served as the basis for a quantitative meta-analysis. In general, dysphagia outcomes after all medialization procedures were strongly positive. Quantitative analysis demonstrated a success rate estimate of 90% (95% CI, 75%-100%) for injection laryngoplasty and 92% (95% CI, 87%-97%) for laryngeal framework surgery. The estimated complication rate was 7% (95% CI, 2%-13%) for injection laryngoplasty and 15% (95% CI, 10%-20%) for laryngeal framework surgery, with minor complications predominating. Although laryngeal reinnervation could not be assessed quantitatively due to low numbers, qualitative analysis demonstrated consistent benefit for a majority of patients for each procedure.

CONCLUSION

Dysphagia due to UVFI can be improved in a majority of patients with surgical procedures intended to improve glottal competence, with a low risk of complications. Injection laryngoplasty and laryngeal framework surgery appear to be efficacious and safe, and laryngeal reinnervation may be a promising new option for select patients.

Treatment Options and Voice Outcomes for Patients With Unilateral Vocal Fold Paralysis After Thyroidectomy

Objectives

This study investigated the treatment options and clinical outcomes of voice therapy (VT), hyaluronic acid (HA) injection, autologous fat injection (FI), and medialization thyroplasty (MT) in patients with unilateral vocal fold paralysis (UVFP) after thyroidectomy.

Study Design

Retrospective case series.

Setting

A tertiary teaching hospital.

Methods

This study included 51 patients with post-thyroidectomy UVFP who underwent VT (n = 20), HA injection (n = 14), FI (n = 12), or MT (n = 5) from January 2016 to June 2021. The treatment outcomes were evaluated using 10-item voice handicap index (VHI-10), maximal phonation time (MPT), and auditory perceptual rating using GRB scales (i.e., grade, roughness, and breathiness) before and 3 to 6 months after treatment.

Results

Patients received HA injection presented a significantly shorter interval after thyroidectomy (mean: 4.6 months), followed by VT (6.7 months), FI (12.3 months), and MT (22.4 months). The results exhibited improvement in most of the outcomes after all of the four treatments. Additional comparisons indicated that VHI-10 scores improved the most among patients receiving MT, followed by HA, FI, and VT. The differences of MPT and GRB scores among the 4 treatment groups were non-significant.

Conclusions

The results revealed that VT, HA, FI, and MT can all improve the voice outcomes of patients with post-thyroidectomy UVFP. The optimal treatment approach should be individualized according to the patient's preference and vocal demand, and the interval between thyroidectomy and intervention.

Functional results of endoscopic arytenoid abduction lateropexy for bilateral vocal fold palsy

Purpose

Endoscopic arytenoid abduction lateropexy (EAAL) is a reliable surgical solution for the minimally invasive treatment of bilateral vocal fold palsy (BVFP), providing a stable airway by the lateralization of the arytenoid cartilages with a simple suture. The nondestructive manner of the intervention theoretically leads to higher regeneration potential, thus better voice quality. The study aimed to investigate the respiratory and phonatory outcomes of this treatment concept.

Methods

61 BVFP patients with significant dyspnea associated with thyroid/parathyroid surgery were treated by unilateral EAAL. Jitter, Shimmer, Harmonics to Noise Ratio, Maximum Phonation Time, Fundamental frequency, Voice Handicap Index, Dysphonia Severity Index, Friedrich’s Dysphonia Index, Global-Roughness-Breathiness scale, Quality of Life, and Peak Inspiratory Flow were evaluated 18 months after EAAL.

Results

All patients had a stable and adequate airway during the follow-up. Ten patients (16.4%) experienced complete bilateral motion recovery with objective acoustic parameters in the physiological ranges. Most functional results of the 13 patients (21.3%) with unilateral recovery also reached the normal values. Fifteen patients (24.6%) had unilateral adduction recovery only, with slightly impaired voice quality. Eleven patients (18.0%) had false vocal fold phonation with socially acceptable voice. In 12 patients (19.7%) no significant motion recovery was detected on the glottic level.

Conclusion

EAAL does not interfere with the potential regeneration process and meets the most important phoniatric requirements while guaranteeing the reversibility of the procedure—therefore serving patients with transient palsy. Further, a socially acceptable voice quality and an adequate airway are ensured even in cases of permanent bilateral vocal fold paralysis.

Data Collection Methods for the Voice Range Profile: A Systematic Review

Purpose To assess data collection variability in the voice range profile (VRP) across clinicians and researchers, a systematic review was conducted to evaluate the extent of variability of specific data collection points that affect the determination of frequency range and sound level and determine next steps in standardization of a VRP protocol. Method A systematic review was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist. Full-text journal articles were identified through PubMed, Web of Science, Psych Info, ProQuest Dissertations and Theses Global, Google Scholar, and hand searching of journals. Results A total of 1,134 articles were retrieved from the search; of these, 463 were duplicates. Titles and abstracts of 671 articles were screened, with 202 selected for full-text review. Fifty-four articles were considered eligible for inclusion. The information extracted from these articles revealed the methodology used to derive the VRP was extremely variable across the data points selected. Additionally, there were eight common acoustic measures used for statistical analysis described in included studies that were added as a data point. Conclusions The data collection methods for the VRP varied considerably. Standardization of procedures was recommended for clinicians and researchers.

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.

Collagen fibrillar structures in vocal fold scarring and repair using stem cell therapy: a detailed histological, immunohistochemical and atomic force microscopy study

Regenerative medicine opens new opportunities in the repair of cicatricial lesions of the vocal folds. Here, we present a thorough morphological study, with the focus on the collagen structures in the mucosa of the vocal folds, dedicated to the effects of stem cells on the vocal folds repair after cicatricial lesions. We used a conventional experimental model of a mature scar of the rabbit vocal folds, which was surgically excised with a simultaneous implantation of autologous bone marrow-derived mesenchymal stem cells (MSC) into the defect. The restoration of the vocal folds was studied 3 months postimplantation of stem cells and 6 months after the first surgery. The collagen structure assessment included histology, immunohistochemistry and atomic force microscopy (AFM) studies. According to the data of optical microscopy and AFM, as well as to immunohistochemical analysis, MSC implantation into the vocal fold defect leads not only to the general reduction of scarring, normal ratio of collagens type I and type III, but also to a more complete restoration of architecture and ultrastructure of collagen fibres in the mucosa, as compared to the control. The collagen structures in the scar tissue in the vocal folds with implanted MSC are more similar to those in the normal mucosa of the vocal folds than to those of the untreated scars. AFM has proven to be an instrumental technique in the assessment of the ultrastructure restoration in such studies. LAY DESCRIPTION: Regenerative medicine opens new opportunities in the repair of the vocal fold scars. Because collagen is a main component in the vocal fold mucosa responsible for the scar formation and repair, we focus on the collagen structures in the mucosa of the vocal folds, using a thorough morphological study based on histology and atomic force microscopy (AFM). Atomic force microscopy is a scanning microscopic technique which allows revealing the internal structure of a tissue with a resolution up to nanometres. We used a conventional experimental model of a mature scar of the rabbit vocal folds, surgically excised and treated with a mesenchymal stem cells transplant. Our morphological study, primarily AFM, explicitly shows that the collagen structures in the scarred vocal folds almost completely restore after the stem cell treatment. Thus, the modern microscopic methods, and especially AFM are instrumental tools for monitoring the repair of the vocal folds scars.

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)

Objective

This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia.

Purpose

The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology–head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology.

Action Statements

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia.

Disclaimer

This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia

Comparison of the use of silastic with titanium prefabricated implant in type I thyroplasty✩✩Please cite this article as: Malik A, Ramalingam WVBS, Nilakantan A, Nair S, Ramesh AV, Raj P. Comparison of the use of silastic with titanium prefabricated implant in type I thyroplasty. Braz J Otorhinolaryngol. 2014;80:156-60

Introdução

A tireoplastia tipo I é o tratamento de escolha nas paralisias unilaterais das pregas vocais que não se recuperam espontaneamente.

Objetivos

Comparar o uso de implante de Silastic® com o uso de titânio pré-fabricado TVFMI® (Titanium Vocal Fold Medializing Implant) na tireoplastia tipo I para o tratamento da paralisia unilateral das pregas vocais com relação à melhora subjetiva e objetiva da voz, às alterações endoscópicas nas pregas vocais, ao tempo de cirurgia e à relação custo-benefício.

Método

Trata-se de um estudo prospectivo com 40 pacientes portadores de paralisia unilateral das pregas vocais submetidos à tireoplastia tipo I com implante de silastic® ou TVFMI®. A avaliação e comparação estatística foram realizadas antes e quatro semanas depois da cirurgia por meio de videolaringoscopia, estroboscopia, análise perceptiva (escala GRBAS-Grade, Roughness, Breathiness, Asthenia, Strain) e subjetiva (IDV-índice de desvantagem vocal) da voz e avaliação eletroglotográfica e avaliação acústica computadorizada. Também foram observados o tempo de cirurgia e o custo do implante.

Resultados

Embora os dois implantes mostrem melhora na qualidade da voz após a tireoplastia, o TVFMI® teve um resultado ligeiramente melhor na análise objetiva da voz. O TVFMI® levou menos tempo de cirurgia para ser inserido, porém foi mais caro.

Conclusão

O TVFMI® poderá ser preferencial na tireoplastia de medialização, já que possui melhores resultados vocais e leva menos tempo de cirurgia, porém é mais caro que o implante de Silastic®.

© 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Todos os direitos reservados.

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

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

Long-term results after external vocal fold medialization thyroplasty with titanium vocal fold medialization implant (TVFMI)

Since its introduction in 1999 by Friedrich, the titanium vocal fold medialization implant (TVFMI) is widely used for medialization thyroplasty in glottal closure insufficiency. The purpose of this study was to investigate the long-term functional outcome after medialization thyroplasty using TVFMI. Between 1999 and 2009 123 patients (mean age 55.3 years, 76 male and 47 female) underwent medialization thyroplasty with the TVFMI (96 left, 27 right). For purpose of long-term follow-up, 33 patients could be examined. Prior to surgery, about 8 weeks and at least 1 year after surgery perceptual, acoustic, aerodynamic and videolaryngostroboscopic examinations have been performed. The interval between surgery and long-term follow-up was on average 57 (23-120) months. None of the 123 patients presented early major postoperative complications (e.g. implant dislocation, dyspnoea with need of tracheostomy, wound infection, postoperative bleeding). In three patients the TVFMI had to be removed 2-6 months after surgery due to granulation tissue formation. In one patient a subepithelial localization of the implant could be seen without necessity of removal. Perceptual and acoustic parameters were significantly improved after surgery with long-lasting effect even years after surgery. Airway resistance (R(aw)) showed an increase over time without a relevant negative impact on the peak expiratory flow (PEF). Medialization thyroplasty using TVFMI allows precise and save positioning of the implant with stable perceptual and acoustic improvement. The only postoperative complication was the development of endolaryngeal granulation tissue resulting in removal of the implant.

[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.

Medialization thyroplasty using autologous nasal septal cartilage for treating unilateral vocal fold paralysis

Objectives

A persistent insufficiency of glottal closure is mostly a consequence of impaired unilateral vocal fold movement. Functional surgical treatment is required because of the consequential voice, breathing and swallowing impairments. The goal of the study was to determine the functional voice outcomes after medialization thyroplasty with using autologous septal cartilage from the nose.

Methods

External vocal fold medialization using autologous nasal septal cartilage was performed on 15 patients (6 females and 9 males; age range, 30 to 57 years). Detailed functional examinations were performed for all the patients before and after the surgery and this included perceptual voice assessment, laryngostroboscopic examination and acoustic voice analysis.

Results

All the patients reported improvement of voice quality post-operatively. Laryngostroboscopy revealed almost complete glottal closure after surgery in the majority of patients. Acoustic and perceptual voice assessment showed significant improvement post-operatively.

Conclusion

Medialization thyroplasty using an autologous nasal septal cartilage implant offers good tissue tolerability and significant improvement of the subjective and objective functional voice outcomes.

Impacts and limitations of medialization thyroplasty on swallowing function of patients with unilateral vocal fold paralysis

CONCLUSIONS

Medialization thyroplasty was effective in improving swallowing function as well as vocal function in most cases with unilateral vocal fold paralysis. The impact of medialization thryoplasty was insufficient for the case with severe atrophy and that in which the vocal fold was fixed in the lateral position.

OBJECTIVES

To evaluate the impacts and limitations of medialization thyroplasty on swallowing function of the patients with unilateral vocal fold paralysis.

METHODS

Eight cases (mean age 68.5 years) with unilateral vocal fold paralysis chiefly complaining of swallowing disturbance were studied. All patients underwent thyroplasty type I. The causes of the paralysis were lung cancer in four cases, esophageal cancer in one case, aortic aneurysm in one case, subarachnoid hemorrhage in one case, and unknown in one case. Subjective swallowing function score, maximum phonation time (MPT), mean flow rate (MFR), amplitude perturbation quotient (APQ), and pitch perturbation quotient (PPQ) were examined pre- and postoperatively.

RESULTS

The swallowing score improved in all except two cases. However, bilateral thryoplasty was necessary for the case with severe vocal fold atrophy and arytenoid adduction was needed for the case in which the vocal fold was fixed in the lateral position. The swallowing score, MPT, and MFR showed significant improvement after surgery.

Type III Thyroplasty for the Treatment of Glottic Gap in a Patient Undergoing Laryngofissure Cordectomy for Squamous Cell Carcinoma of the Vocal Fold: Technique and Outcome

A 44-year-old man presented with squamous cell carcinoma (T1aN0M0) on the left vocal fold and was prepared for a combined laryngofissure cordectomy and type III thyroplasty. The author performed both procedures together—not only to lower the tension on the healthy vocal fold, but also to determine whether the thyroplasty would successfully close the glottic gap created by the cordectomy, resulting in relatively fast improvement in the patient's voice. Satisfactory glottic closure and a satisfactory voice result were achieved rather quickly. The patient was satisfied with his new voice, both in the early and late postoperative periods.

Multiparameter analysis of titanium vocal fold medializing implant in an excised larynx model

OBJECTIVES

We evaluated the efficacy of the titanium vocal fold medializing implant (TVFMI) for the treatment of unilateral vocal fold paralysis (UVFP) on the basis of acoustic, aerodynamic, and mucosal wave measurements in an excised larynx setup.

METHODS

Measurements were recorded on 8 excised canine larynges with simulated UVFP before and after medialization with a TVFMI.

RESULTS

The phonation threshold flow (p < 0.001) and phonation threshold power (p = 0.008) decreased significantly after medialization. The phonation threshold pressure also decreased, but this difference was not significant (p = 0.081). Jitter (p = 0.005) and shimmer (p = 0.034) decreased significantly after medialization. The signal-to-noise ratio increased significantly (p = 0.05). Differences in mucosal wave characteristics were discernible but not significant. The phase difference between the normal and paralyzed vocal folds (p = 0.15) and the amplitude of the paralyzed vocal fold (p = 0.78) decreased. The glottal gap decreased significantly (p = 0.004).

CONCLUSIONS

The TVFMI was effective in achieving vocal fold medialization, improving vocal aerodynamic and acoustic characteristics of phonation significantly and mucosal wave characteristics discernibly. This study provides objective, quantitative support for the use of the TVFMI in improving vocal function in patients with UVFP.

Intracordal fat assessment by 3-dimensional imaging after autologous fat injection in patients with thyroidectomy-induced unilateral vocal cord paralysis

BACKGROUND

Complications of thyroidectomy are the most frequent cause of unilateral vocal cord paralysis (UVCP) in Taiwan. Autologous fat injection for UVCP is a well-established procedure for temporary symptom relief. The aims of this study were to identify the long-term residual fat volume by 3-dimensional computed tomography (3-D CT) and to investigate the voice outcome.

METHODS

During this cross-sectional study, 28 consecutive patients who had undergone lipoinjection surgery for symptomatic UVCP resulting from thyroidectomy were enrolled. They received 3-D CT evaluations of the larynx and upper airway after lipoinjection surgery to assess the residual fat volume.

RESULTS

The mean duration from lipoinjection surgery to 3-D CT study was 26 months (range, 12-58). The mean residual fat volume remained consistent (0.39 +/- 0.35 mL; range, 0.01-1.6). The maximal phonation time, s/z ratio, jitter, and harmonic-to-noise ratio were significantly improved during follow-up.

CONCLUSION

Injected fat can survive chronically and provide clinically important improvement in voice in the patients with throidectomy-induced UVCP.

Palliative treatment of dysphonia and dysarthria

The focus of this article is the palliative treatment of a variety of dysphonic conditions. Symptomatic relief of hoarseness can be achieved by voice therapy, augmentative alternative communication modalities, and surgery. The causes of dysphonia addressed herein include amyotrophic lateral sclerosis, Parkinson's disease, multiple sclerosis, stroke, head and neck cancers requiring glossectomy or laryngectomy, unilateral vocal fold paralysis, and presbyphonia. Palliative treatment of dysphonia and voice disorders provides symptomatic relief but not a cure of the underlying disease state. For these patients there are a number of palliative interventions that can greatly improve their quality of life.

Role of Subglottal Shape in Turbulence Reduction

Objectives:

In previous work, we found that airflow at the superior edge of the vocal folds, in the excised canine larynx, can be laminar even when the tracheal airflow is predominantly turbulent. Turbulent flow directly above the folds may lead to an irregular or “rough” voice. Thus, it is important to determine the mechanism of turbulence reduction. From fluid mechanics, it is known that a smoothly converging duct will reduce turbulence. In this study, we tested the hypothesis that the majority of the turbulence reduction is due to the smooth converging shape of the subglottis.

Methods:

In 3 excised canine larynges, hot-wire anemometry was used to measure the turbulence intensity (TI) below the cricoid cartilage and 2 to 3 mm above the superior edge of the vocal folds. Laminar flow was seen when the TI was approximately less than 2%. For our measurements, flow into the subglottis had an average TI of more than 20% (high turbulence) in the shear layer and a TI of more than 15% in the center of the jet. The larynges were tested under steady conditions (folds not phonating) with the vocal processes approximated.

Results:

For the center of the jet, there is moderate turbulence below the cricoid cartilage and laminar flow 2 to 3 mm above the folds. For the shear layer, there is very high turbulence below the cricoid cartilage and low turbulence 2 to 3 mm above the folds.

Conclusions:

The smooth converging shape of the subglottis can produce a significant reduction in turbulence. These findings may have important voice implications for operations that may change the subglottal shape (such as vocal fold medialization or airway reconstruction).

Functional outcome of vocal fold medialization thyroplasty with a hydroxyapatite implant

OBJECTIVES

Unilateral vocal fold paralysis can cause a persistent incomplete glottal closure during phonation, resulting in impaired voice function. The aim of this study was to evaluate functional results of medialization thyroplasty using a hydroxyapatite implant (VoCoM).

STUDY DESIGN

Prospective observational cohort study.

METHODS

Between 1999 and 2003, a total of 26 patients (19 men, 7 women) undergoing medialization thyroplasty using a hydroxyapatite implant because of unilateral vocal fold paralysis were enrolled in the study. To evaluate voice function, the following parameters were measured preoperatively and postoperatively: mean fundamental frequency, mean sound pressure level, frequency and amplitude range (voice range profile), and maximum phonation time. A perceptual assessment of hoarseness was conducted using the Roughness, Breathiness, Hoarseness scale. Furthermore, the magnitude of voice related impairment of the patient's communication skills was rated on a 7-point scale. A combined parameter called the Voice Dysfunction Index (VDI) was used to rate vocal performance.

RESULTS

All patients showed a statistically significant improvement in the VDI, in perceptual voice analysis, in maximum phonation time, and in the dynamic range of voice. One patient experienced a postoperative wound hemorrhage as a minor complication. No further complications or implant extrusions were observed.

CONCLUSIONS

Medialization thyroplasty using a hydroxyapatite implant is a secure and efficient phonosurgical procedure. Voice quality and patient satisfaction improve significantly after treatment.

Maximum Duration of Sustained /s/ and /z/ and the s/z Ratio With Controlled Intensity

SUMMARY

The purpose of this study was to compare maximum prolongations of controlled-intensity /s/ vs. /z/ in young healthy male and female adults and to compare the s/z ratio in young men and women. Twenty young adult men and 20 young adult women were included in this study. Participants produced 10 trials of /s/ and 10 of /z/ with a controlled intensity of 60-dB sound-pressure level (SPL). Maximum prolongations and s/z ratio were determined by three different methods: based on the longest out of 10 trials, the longest of 3 trials, and an average of the first 3 trials. Results revealed that based on averaged group data, /s/ and /z/ seemed to be prolonged for similar durations. Men consistently prolonged both phonemes significantly longer than women. There were no significant differences in s/z ratio between men and women. However, when individual data were reviewed, it seemed that some subjects consistently prolonged /s/ for a longer duration than /z/, some subjects prolonged /z/ longer than /s/, and some subjects actually produced approximately equal durations of the two phonemes. It was further noted that /s/ durations were more favorably impacted by practice than /z/ durations.

[Management of oropharyngeal dysphagia. Current status]

The diagnostics and therapy of oropharyngeal dysphagia fall within the competence of ENT, phoniatrics and speech language pathology. Due to etiologic diversity, interdisciplinary management is necessary in many cases. After taking a thorough history, focused on swallowing, dynamic instrumental examination methods, i.e. videoendoscopic and videofluoroscopic swallowing studies, allow an evaluation of the morphology and function of the act of swallowing. Videoendoscopic swallowing studies enable the ENT specialist/phoniatrician to decide on further diagnostic steps, to establish a therapy and to recommend the type of feeding (oral, non-oral). Therefore, in clinical routine, knowledge of the diagnostics and therapy of swallowing disorders is indispensable for the ENT specialist/phoniatrician.

Soft Tissue Response of the Larynx to Silicone, Gore-Tex, and Irradiated Cartilage Implants

OBJECTIVE

The aim of the study is to compare the efficiency of three different materials (Silicone, Gore-Tex, and irradiated cartilage) used in medialization laryngoplasty. Local tissue reaction to implants in laryngeal skeleton has been examined for this purpose.

STUDY DESIGN AND METHODS

In this prospective study, New Zealand rabbits were used. Different materials have been implanted in the paraglottic space of both sides of the larynx to enable a better comparison of the different materials used. Limited medialization was applied. Special care has been taken not to narrow the airway and cause breathing problems. The reaction of the tissue in this region against the materials used has been studied. Each material was implanted 14 times in total. The rabbits were killed 6 months after the implementation to study their larynx. For each material, the fibrous capsule formation, histiocyte infiltration, foreign body giant cell infiltration, eosinophil infiltration, neutrophil infiltration, and lymphoplasmacytic infiltration levels were investigated histologically.

RESULTS

Best fibrous capsule formation has been observed around silicone. Allergic reactions and inflammatory responses were minimal for this material. Fibrous capsule formation was more limited with Gore-Tex. Some degree of chronic inflammatory response (in few cases) has been observed against this material. Severe allergic response was observed against irradiated cartilage, and the implant material was resorbed completely in most cases.

CONCLUSION

According to histopathologic results of this study (tissue compatibility of three materials), silicone is the most suited material among the study materials for medialization. Gore-Tex can also be used for this purpose. Irradiated cartilage, on the other hand, appears not to be a suitable material for medialization laryngoplasty.

Perceptual ratings of vocal characteristics and voicing features in untreated patients with unilateral vocal fold paralysis

This study used visual analog scales to obtain perceptual ratings of features of voice production in subjects with unilateral vocal fold paralysis (UVFP), including clarity of laryngeal articulation, consistency of loudness across the utterance and the voiced/voiceless distinction. Recordings of repeated /i/, /isi/, and /izi/ from subjects diagnosed with UVFP and control subjects were randomly re-recorded, and then rated by five listeners. Significant differences in ratings (Smirnov test, p < 0.01) were found between groups for "aphonia", "severity", "clarity of articulation", "overall loudness", "consistency of loudness" and "amount of effort". Four of five raters agreed on the accuracy of /s/ or /z/ productions for only 54% of the samples from the subjects with UVFP. Voiceless and voiced cognates were equally likely to be rated as inaccurate. Results suggested that these variables were sensitive to changes in voice production resulting from paralysis, and may be useful in measuring treatment outcomes and spontaneous recovery of function.

LEARNING OUTCOMES

As a result of reading this manuscript the reader will (1) gain an understanding of types of perceptual scales and how to develop the set of vocal characteristics to be used in distinguishing patients with UVFP and those without, (2) learn which vocal characteristics listeners are able to use to successfully distinguish between patients with UVFP and those without and (3) understand the possible role for perceptual ratings in tracking changes in vocal characteristics in subjects over time following treatment or spontaneous recovery of function.

Multidimensional assessment of functional outcomes of medialization thyroplasty

Medialization thyroplasty (MT) is the most widely used laryngeal framework phonosurgical procedure for managing glottic incompetence secondary to unilateral vocal fold paralysis (UVFP). The aim of the study was to evaluate the functional outcomes of MT in 32 UVFP patients, comparing multidimensional perceptual and instrumental measures of voice before and after surgery, and to evaluate how close to normal that postoperative voice measure became. Video laryngostroboscopy (VLS), auditory perceptive evaluation of voice, the patients' self-evaluation of hoarseness on the Visual Analogue Scale (VAS) and calculation of the Voice Handicap Index (VHI), analysis of objective acoustic voice parameters, quantitative assessment of phonetograms and measurement of maximum phonation time were conducted. Vocal function was evaluated before the surgery and for the period from 1 month to 3 years (Mo 1.0 month; Me 2.0 months) after MT. VLS confirmed remarkable medialization of the paralyzed vocal fold. As a consequence, hoarseness and breathiness were found to be significantly decreased after MT. Pitch and intensity range and phonetogram area were significantly increased. A significant decrease of jitter, shimmer and normalized noise energy reflected improvement of the stability of acoustic signal and a more efficient pattern of phonation. Thus, the perceptual and acoustic voice parameters studied showed statistically significant differences (P < 0.001) between preoperative and postoperative voices, and these objective measurements of voice changes provided accurate and documentary evidence of the results of surgical treatment. A high degree of patient satisfaction with the MT was confirmed by a significant decrease of VHI and hoarseness on VAS. Thus, results of the present investigation confirm the functionality and effectiveness of MT in patient voice rehabilitation with UVFP. However, the means of acoustic voice parameters measured in the study did not reach normal limits, probably because of the remaining underlying condition of UVFP.

Perspectives on medialization laryngoplasty

Medialization laryngoplasty has become the new gold standard for the permanent management of patients with vocal fold paralysis and paresis. This article reviews the conceptual developments of the diagnosis and management of patients with vocal fold paresis and paralysis. We identify the specifics of operative decision-making as well as surgical complications associated with medializationlaryngoplasty. The role of revision surgery is detailed. We suggest a standardized evaluation using both objective and subjective data for analysis of surgical outcomes.

Aerodynamic measurements in medialization thyroplasty

OBJECTIVE

External vocal fold medialization thyroplasty is a standard technique for improving voice, swallowing and breathing impairments due to insufficient glottal closure caused by either unilateral vocal fold paralysis or deficit of vocal fold tissue (i.e. as a result of cordectomy, scarring processes or sulcus glottidis). However, only scant information is available concerning the effect of the medialization thyroplasty on aerodynamic parameters. The aim of this study was to investigate the effect of vocal fold medialization thyroplasty on the degree of laryngeal stenosis using selected aerodynamic parameters.

MATERIAL AND METHODS

Thirty patients (12 female, 18 male) underwent external vocal fold medialization with a titanium vocal fold medialization implant under local anesthesia supplemented by i.v. sedation. Pulmonary function tests were performed pre- and postoperatively and selected parameters were analyzed statistically.

RESULTS

All patients reported improved self-control of breathing during speaking, laughing, coughing and physical activity. The postoperative values of the parameters tested showed no significant alteration in comparison to the preoperative data.

CONCLUSIONS

The analysis of the aerodynamic findings indicated that the medialization procedure using an implant did not cause an increase in the laryngeal resistance.