Factors Associated With Improvement Following In-office Steroid Injections for Vocal Fold Scar

OBJECTIVE

This study aims to evaluate the clinical outcomes of patients receiving in-office vocal fold steroid injections (VFSI), highlighting relatively new measures around vocal pitch.

METHODS

Patients with a diagnosis of vocal fold scar who received in-office VFSI from 2013 to 2024 were evaluated. Pre- and post-steroid Voice Handicap Index (VHI-10) scores, stroboscopic vibratory parameters, acoustic measures of cepstral peak prominence (CPP), and fundamental frequency coefficient of variation (F0CoV) during sustained phonation were analyzed using Wilcoxon signed-rank tests and McNemar's tests.

RESULTS

Twenty-two patients had follow-up data 1-3 months after steroid injection. The median decrease in VHI-10 after one injection was 4 points (p = 0.02). We found no difference in CPP and F0CoV measures at follow-up. Forty-five percent of patients improved in mucosal wave and amplitude of at least one vocal fold. Earlier presentation from vocal injury was associated with improvement in mucosal wave and amplitude of the left vocal fold (p = 0.03). We found no difference in sex, tobacco smoking history, singing status, secondary diagnosis, and baseline VHI-10 score between patients who improved in vibratory parameters and those who did not.

CONCLUSION

This single-center study is one of the largest exploring patient outcomes following in-office VFSI. Though patients reported modest improvement in voice use after VFSI, this may not be as impactful as previously believed. Improvement in videostroboscopy is expected in about half of the patients, with recency from vocal injury a likely predictor of success. These partially negative results provide insight into counseling patients regarding benefits from in-office VFSI.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Efficacy of platelet-rich plasma (PRP) in benign vocal fold lesions: a systematic review and meta-analysis

OBJECTIVES

To evaluate the efficacy of platelet-rich plasma (PRP) in benign vocal fold lesions.

METHODS

MEDLINE, Cochrane Central, Web of Science, and Scopus databases were searched in April 2023 for relevant clinical trials. Inclusion criteria were clinical trials evaluating the efficacy of PRP in benign vocal fold lesions. We conducted a comparative double-arm analysis using the pooled mean difference (MD) and 95% confidence interval (CI). Outcomes of interest included the vocal handicap index (VHI), the Jitter and Shimmer percentages, and the noise-to-harmonic ratio (NHR).

RESULTS

Six studies matched the inclusion criteria. The pooled analysis shows that PRP was associated with significantly lower VHI scores compared with the control (MD = - 5.06, p < 0.01). Regarding the Jitter percentage, the PRP group was not superior to the control group at 2 and 4 weeks. However, the results revealed that PRP significantly reduced the Jitter percentage at 3 months (MD = - 0.61, p = 0.0008). The overall analysis favored the PRP arm significantly (p < 0.001). As for the Shimmer percentage, the combined effect estimate favored the PRP group (MD = - 1.22, p = 0.002). Subgroup analysis according to the time did not reveal any significant differences between studies at 2 weeks, 4 weeks, and 3 months. The analysis of the NHR outcome revealed a significant difference between both groups (MD = -1.09, p = 0.01). However, at 4 weeks, the treatment group had a significantly lower NHR % compared to the control group (MD = - 0.61, p = 0.02). There was no significant difference at 3 months (MD = - 2.14, p = 0.14).

CONCLUSIONS

Platelet-rich plasma is effective in reducing VHI scores, Jitter and Shimmer percentages, and NHR values. This effect is more evident after follow-up, especially 3 months.

Duration of Clinical Response After In-Office Steroid Injection for Vocal Fold Scar

OBJECTIVE

To assess the duration of clinical response after in-office vocal fold steroid injection (VFSI) for vocal fold (VF) scar.

METHODS

Demographic and clinical data for in-office VFSI occurring from 2017 to 2020 were collected. Two Speech-Language Pathologists (SLPs) used perceptual evaluation of voice and functional scales to evaluate blinded voice and laryngovideostroboscopy (LVS) samples collected pre- and post-injection across multiple timepoints.

RESULTS

Blinded SLP ratings were used for 30 individual VFs undergoing initial injection in 18 patients. Persistent improvement in voice past 6 months was seen in 57% of patients after VFSI. Multiple measures of voice and amplitude, percent vibrating tissue, and closed phase predominance significantly improved at various follow-up timepoints on average.

CONCLUSION

Accounting for patient heterogeneity and disease progression, in-office VFSI for VF scar is associated with sustained improvement in a subset of patients. Approximately half of patients can expect to experience a lasting improvement in voice. Future studies of larger scale are required to identify patient factors associated with long-term benefit.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2333-2339, 2023.

Options for treatment of a small glottic gap

Background

Glottic insufficiency, or glottic gap as it is commonly called, is a common cause of dysphonia, producing symptoms of soft voice, decreased projection, and vocal fatigue. The etiology of glottic gap can occur from issues related to muscle atrophy, neurologic impairment, structural abnormalities, and trauma related causes. Treatment of glottic gap can include surgical and behavioral therapies or a combination of the two. When surgery is chosen, closure of the glottic gap is the primary goal. Options for surgical management include injection medialization, thyroplasty, and other methods of medializing the vocal folds.

Methods

This manuscript reviews the current literature regarding the options for treatment of glottic gap.

Discussion

This manuscript discusses options for treatment of glottic gap, including the indications for temporary and permanent treatment modalities; the differences between the available materials for injection medialization laryngoplasty and how they affect the vibratory function of the vocal folds and vocal outcome; and the evidence that supports an algorithm for treatment of glottic gap.

Level of Evidence

3a-Systematic review of case-control studies.

Safety of Platelet-Rich Plasma Subepithelial Infusion for Vocal Fold Scar, Sulcus, and Atrophy

OBJECTIVE

To demonstrate the safety profile of platelet-rich plasma (PRP) as an injectable therapeutic for the treatment of vocal fold scarring and atrophy.

METHODS

Preliminary report on a prospective clinical trial of patients with vocal fold scar or atrophy undergoing unilateral vocal fold subepithelial infusion with autologous PRP. Enrolled patients underwent four subepithelial injections spaced 1 month apart. Adverse events were assessed peri and post-injection at each session. Patient-reported outcomes were collected at every visit using the Voice Handicap Index-10 (VHI-10) and Vocal Fatigue Index (VFI) questionnaires.

RESULTS

Twelve patients underwent unilateral vocal fold injection with autologous PRP prepared according to Eclipse PRP® system protocol. Forty-three injections were performed using a peroral or percutaneous approach. An average of 1.57 ± 0.4 cc (range 0.6-2.0 cc) injectate was used. All patients tolerated the procedure without difficulty or peri-procedural complications. The average duration of follow-up was 3.6 ± 1.8 months. No significant inflammatory reactions or adverse events were seen to date. There was statistically significant improvement in patient-reported outcomes at the 3 month follow up (n = 9) follow-up (mean ΔVHI-10 = 10.8, p < 0.001, mean ΔVFI = 18.9, p = 0.01, t test, paired two sample for means, two-tail). All nine patients who completed the series of four injections subjectively (yes/no) reported they were satisfied with the results.

CONCLUSION

This prospective study cohort demonstrated a favorable safety profile, with no adverse events or peri-procedural complications. Subjective improvements in vocal quality and reduction in vocal fatigue need to be clinically correlated with further study.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:647-653, 2023.

Platelet-Rich Plasma for Vocal Fold Scar: A Preliminary Report of Concept

INTRODUCTION

Vocal fold atrophy and scar can lead to loss of normal superficial lamina propria, negatively affecting the vibratory function of the vocal fold. These changes can lead to dysphonia, vocal fatigue, decreased volume, and altered pitch. Treatment options for these conditions are limited. Platelet-rich plasma (PRP) consists of platelets, growth factors, and cytokines derived from the patient's own blood and is believed to activate tissue regeneration. The purpose of this study was to review the technical aspects of collecting PRP and injecting it into the vocal fold injection - based on our initial experience with this procedure.

CASE

A patient with vocal fold scar was identified and enrolled in an ongoing prospective clinical trial study of a series of 4 monthly subepithelial vocal fold PRP injections, which was temporarily halted due to the COVID-19 pandemic. Patient underwent a single injection of autologous PRP into the left vocal fold. There were no adverse events during the study period. Subjective improvement in voice was noted at 1 month after injection with subsequent return to baseline over the next 4 months. Videostroboscopy performed on postinjection day 1 and day 7 and demonstrated no concerning exam changes. Compared to the preinjection baseline, the patient-reported voice-handicap index-10 (VHI-10) and voice catastrophization index were similar at 4 months following injection (20 to 20 and 4 to 3, respectively). Independent perceptual analysis of voice showed improvement at 4 months postinjection, compared to baseline consensus auditory-perceptual evaluation of voice 60 to 44.

CONCLUSIONS

This preliminary report was part of a prospective trial investigating the use of PRP to treat vocal fold atrophy and scar. This work highlights the technical considerations for injecting PRP into the vocal fold. Planned prospective enrollment in this study will help to validate the safety and efficacy of PRP injections.

Creation and Implementation of the UCSF Laryngeal Symptom Diary for Trial Vocal Fold Injection

OBJECTIVES

Patient recollection of their trial vocal fold injection outcomes is crucial in determining future treatment. This study aims to assess a new clinical tool, the UCSF Laryngeal Symptom Diary, for its ease of use, clinical value in patient symptom tracking, and utility for long-term decision-making following trial vocal fold injection.

MATERIALS AND METHODS

In this prospective cohort study, consecutive patients undergoing trial vocal fold injection between June 2019 and January 2020 completed the UCSF Laryngeal Symptom Diary. Patients rated standardized and customized laryngeal symptoms weekly. Upon follow-up, a survey pertaining to the diary was completed by both the patient and treating laryngologist.

RESULTS

A total of 29 patients opted to participate and were provided with the UCSF Laryngeal Symptom Diary. The diary was returned by 82.3% (n = 24/29) of patients. Mean time to follow up was 5.98 weeks. Survey participation rate was 93.1% (n = 27/29). From the patients' perspective, 66.7% (n = 18/27) found the diary useful in following their symptom evolution. Treating laryngeal surgeon noted excellent concordance between diary entries and patient's overall injection benefit (91.7%, n = 22/24). The diary was useful in clinician-recommendation of subsequent treatment options in 70.8% (n = 17/24) of patients.

CONCLUSION

The UCSF Laryngeal Symptom Diary is a patient friendly clinical tool for trial vocal fold injection that facilitates patient tracking of symptom evolution and helps guide treating clinicians in subsequent treatment planning.

Bilateral medialization thyroplasty in patients with vocal fold atrophy with or without sulcus

Purpose

To evaluate voice outcome after bilateral medialization thyroplasty in patients with non-paralytic glottic insufficiency due to vocal fold atrophy with or without sulcus.

Methods

Retrospective cohort study on 29 patients undergoing bilateral medialization thyroplasty for vocal fold atrophy (14 procedures) or atrophy with sulcus (15 procedures) between October 2012 and November 2017. Voice data were collected and analyzed for the preoperative and the 3- and 12-month postoperative time point according to a standardized protocol, including Voice Handicap Index (VHI)-30 and perceptual, acoustic and aerodynamic parameters. Failure rate was based on number of revisions within 12 months and non-relevant improvement (< 10 points) in VHI-30 at 12 months.

Results

There was a clinically relevant (≥ 15 points) and statistically significant improvement (p < 0.0001) in the VHI-30 (preoperative: 55.8 points; postoperative at 12 months: 30.9 points). Fundamental frequency for male subjects decreased significantly from 175 to 159 Hz (p = 0.0001). The pre- and post-operative grade of dysphonia was significantly lower in patients with atrophy compared to atrophy and sulcus (mean difference 0.70, p = 0.017).

Conclusion

Bilateral medialization thyroplasty is a valid treatment option for patients with atrophy with or without sulcus. Outcomes are comparable to other methods reported in literature. However, there is a great need for larger, prospective studies with long-term follow-up to gain more insight into the comparative voice outcomes for the different forms of surgery for patients with glottic incompetence due to atrophy with or without sulcus.

Bilateral trial vocal fold injection with hyaluronic acid in patients with vocal fold atrophy with or without sulcus

Purpose

To evaluate the outcome of bilateral trial vocal fold injection (VFI) with hyaluronic acid in patients with vocal fold atrophy ± sulcus and to assess the predictive value of trial VFI on the outcome of durable medialization procedure.

Methods

Voice data collected according to a standardized protocol before and one month after trial VFI of 68 patients with vocal fold atrophy (30) and atrophy with sulcus (38) were analyzed. Voice Handicap Index (VHI)-30 was compared to the outcome of a durable medialization at 3 and 12 months.

Results

The overall VHI-30 improvement was 16.8 points (from 49.9 to 33.1), which was statistically significant and clinically relevant. 57.8% of the patients experienced enough subjective benefit after trial VFI to undergo durable medialization. Of the patients that experienced subjective benefit 62% had a clinically relevant improvement in VHI-30. There was no relevant change in other parameters and no difference between ± sulcus. After durable medialization 90–94% of the patients had VHI-30 scores similar to or better than post-trial VFI.

Conclusion

The majority of patients experience subjective improvement after bilateral trial VFI indicating that medialization is a valid treatment option for patients with vocal fold atrophy ± sulcus. The VHI-30 only partially overlaps with patients’ subjective evaluation and does not predict which patients will experience subjective improvement. It is, however, predictive for VHI-30 outcome after durable medialization. The aerodynamic and acoustic parameters showed no relevant change. Further identification of voice assessment parameters accurately reflecting the subjective experience of these patients is warranted.