Evaluation and treatment of the unilateral paralyzed vocal fold

De novo tissue formation using custom microporous annealed particle hydrogel provides long-term vocal fold augmentation

Biomaterial-enabled de novo formation of non-fibrotic tissue in situ would provide an important tool to physicians. One example application, glottic insufficiency, is a debilitating laryngeal disorder wherein vocal folds do not fully close, resulting in difficulty speaking and swallowing. Preferred management of glottic insufficiency includes bulking of vocal folds via injectable fillers, however, the current options have associated drawbacks including inflammation, accelerated resorption, and foreign body response. We developed a novel iteration of microporous annealed particle (MAP) scaffold designed to provide persistent augmentation. Following a 14-month study of vocal fold augmentation using a rabbit vocal paralysis model, most MAP scaffolds were replaced with tissue de novo that matched the mixture of fibrotic and non-fibrotic collagens of the contralateral vocal tissue. Further, persistent tissue augmentation in MAP-treated rabbits was observed via MRI and via superior vocal function at 14 months relative to the clinical standard.

Inducible Laryngeal Obstruction Differential Diagnosis in Adolescents and Adults: A Tutorial

Inducible laryngeal obstruction (ILO), formerly referred to as paradoxical vocal fold motion and vocal cord dysfunction, is a complex disorder of the upper airway that requires skillful differential diagnosis. There are several medical conditions that may mimic ILO (or which ILO may mimic) that should be considered in the differential diagnosis before evidence-supported behavioral intervention is initiated to mitigate or eliminate this upper airway condition. A key in treatment planning is determination of an isolated presentation of ILO or ILO concurrent with other conditions that affect the upper airway. Accurate, timely differential diagnosis in the clinical assessment of this condition mitigates delay of targeted symptom relief and/or insufficient intervention. Accurate assessment and nuanced clinical counseling are necessary to untangle concurrent, competing conditions in a single patient. This tutorial describes the common and rare mimics that may be encountered by medical professionals who evaluate and treat ILO, with particular attention to the role of the speech-language pathologist. Speech-language pathologists receive referrals for ILO from several different medical specialists (allergy, pulmonology, and sports medicine), sometimes without a comprehensive team assessment. It is paramount that speech-language pathologists who assess and treat this disorder have a solid understanding of the conditions that may mimic ILO. Summary tables that delineate differential diagnosis considerations for airway noise, origin of noise, symptoms, triggers, role of the speech-language pathologist, and β-agonist response are included for clinician reference. A clinical checklist is also provided to aid clinicians in the critical assessment process.

Aerodynamic Performance and Neuromuscular Control in Patients with Unilateral Vocal Fold Paralysis

Unilateral vocal fold paralysis (UVFP) causes glottal incompetence and poor vocal efficiency. The influence of laryngeal neuromuscular control on aerodynamics in UVFP remains unclear. This study investigated the relationship between laryngeal muscle activities using quantitative laryngeal electromyography (LEMG) and aerodynamics in UVFP. This prospective study recruited patients with UVFP, and the diagnosis was confirmed with videolaryngostroboscopy and LEMG. The patient received aerodynamic assessment and LEMG of the thyroarytenoid-lateral cricoarytenoid (TA-LCA) muscle complex and the cricothyroid (CT) muscle. The relationship between quantitative LEMG and aerodynamic parameters was analyzed. A total of 134 UVFP patients without concurrent CT muscle involvement were enrolled. Compared with the normal side, the peak turn frequency of the lesioned side was lower in the TA-LCA (p < 0.001) and CT (p = 0.048) muscles. Stepwise linear regression revealed that the turn ratio of TA-LCA muscles was a robust factor in the decrease in peak expiratory airflow (β = −0.34, p = 0.036), mean airflow during voicing (β = −0.28, p = 0.014), and aerodynamic power (β = −0.42, p = 0.019), and an increase in aerodynamic efficiency (β = 27.91, p = 0.012). In addition, the turn ratio of CT muscles was a potent factor in inducing an increase in aerodynamic resistance (β = 14.93, p = 0.029). UVFP without CT involvement still showed suppression of CT muscles on the lesioned side, suggesting that neurological impairment of the TA-LCA complex could cause asymmetrical compensation of CT muscles, further impeding aerodynamics. The residual function of TA-LCA muscle complexes facilitates less air leakage and power dissipation, enhancing aerodynamic efficiency. On the other hand, the symmetrical compensation of the CT muscles improves aerodynamic resistance.

[Predictive value of strobovideolaryngoscopy, acoustic and aerodynamic measures in the prognosis of temporally unilateral vocal fold paralysis after thyroidectomy]

Objective:To investigate the strobovideolaryngoscopy, acoustic and aerodynamic characteristics of transient unilateral vocal ford paralysis（UVFP） after thyroidectomy. Methods:A retrospective analysis was made of 11 patients with temporary UVFP after thyroidectomy who were treated in Department of Otolaryngology and Head and Neck Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University from January 2013 to March 2021; 8 patients with permanent UVFP after thyroidectomy during the same period were included as a control group. The differences in baseline strobovideolaryngoscopy, acoustic and aerodynamic measures were compared between the two groups. Results:The tones of patients with temporary UVFP after thyroidectomy were all normal, and the proportions of abnormal vocal fords（vocal ford bowing, atrophy, and shortening）, ventricular adduction and glottic insufficiency were significantly lower than those of permanent UVFP patients; arytenoid cartilage stability and height mismatch of vocal ford tended to be better than permanent UVFP. The maximal phonation time（MPT） in patients with temporary UVFP was （8.5±4.1） s, which was significantly longer than （3.9±2.1） s in patients with permanent UVFP; fundamental frequency, mean airflow（MeAF） and mean subglottic pressure（SGP） were better in temporary UVFP than those in patients with permanent UVFP, but the difference did not reach statistical significance. Conclusion:None and mild glottic insufficiency, normal tone, ventricular adduction, and vocal ford appearances without vocal fold bowing, atrophy, and shortening, can be served as the predictors for the early recovery of vocal ford movement in temporary UVFP after thyroidectomy. The MPT less than 4 s, and MeAF, and SGP remarkably increased is the predictor of poor prognosis for vocal ford recovery.

Demographic differences in the treatment of unilateral vocal fold paralysis

Objective

To determine the impact of patient demographics and social determinants of health on treatment pathways for unilateral vocal fold paralysis (UVFP) at a tertiary laryngology clinic.

Study design

Retrospective medical record review.

Methods

Patient demographics (age, gender, race, ethnicity, and insurance status) were extracted for adults diagnosed with UVFP between 2009 and 2019. Odds ratios for the associations between sociodemographic factors and UVFP treatment pathways were determined by chi-square analyses.

Results

A total of 1490 UVFP diagnoses were identified during the study period with the majority being female (58%), White (85%), non-Hispanic (97%), and publicly insured (54%). Five treatment pathways were identified: observation, injection laryngoplasty, voice therapy, laryngeal framework surgery/thyroplasty, and reinnervation surgery. There were 538 patients who underwent observation, 512 injection laryngoplasty, 366 voice therapy, 136 thyroplasty, and 26 laryngeal reinnervation surgery. Males were more likely to undergo injection laryngoplasty than females (OR 1.32; CI 1.08-1.61), whereas females were more likely to undergo voice therapy (OR 1.39; CI 1.09-1.76). Patients with public insurance (OR 1.48; CI 1.03-2.14) and Hispanics (OR 2.60; CI 1.18-5.72) were more likely to undergo thyroplasty. Patients who underwent reinnervation surgery were younger than those in other treatment pathways (median: 39.1 years vs. 50.7-56.1 years).

Conclusions

Gender, ethnicity, and insurance status were significantly associated with specific UVFP treatment pathways. Patients with public insurance were more likely to undergo surgical intervention than voice therapy. This data overall supports differences in care pathway utilization for UVFP based on social determinants of health.

Level of evidence

Level IV.

Impact of Pulmonary Function on Voice Outcomes After Injection Laryngoplasty for Unilateral Vocal Fold Paralysis

OBJECTIVES

Pulmonary function is closely associated with voice quality especially in patients with voice disorder including unilateral vocal fold paralysis (UVFP). Injection laryngoplasty (IL) is the standard treatment for patients with UVFP. We investigated the subjective and objective voice outcomes according to pulmonary function test (PFT) before IL in patients with UVFP.

METHOD

We retrospectively analyzed the patients who underwent IL for UVFP between 2004 and 2021 (N = 1201), and finally investigated 261 patients with PFT results before IL. The patients were classified into three groups according to results of PFT: normal (n = 189, 72%), mild (n = 40, 15%), and moderate (n = 32, 13%) obstructive pattern. Aspiration symptoms and subjective and objective voice parameters of voice handicap index (VHI), GRBAS score, maximal phonation time (MPT), Jitter, Shimmer, and noise to harmonic ratio (NHR) were compared between normal and abnormal (mild or moderate obstructive pattern) PFT groups.

RESULTS

Age (68.0 ± 9.1 and 61.2 ± 12.6, respectively) was significantly higher and males were more common (84.7% and 57.7%, respectively) in abnormal PFT than in normal PFT. Aspiration showed significant improvement in all groups. The subjective and objective voice parameters significantly improved after IL in normal and mild obstruction groups, but MPT, Shimmer, and VHI did not significantly improve in the moderate obstruction group. The improvement in VHI-30 after IL was significantly higher in the normal group (20.0 ± 29.5) than in the mild (10.3 ± 32.8) or moderate (9.9 ± 33.2) obstruction group (P = 0.035). Improved amounts of MPT, Jitter, Shimmer, and NHR were not significantly different among the groups, but improvement of VHI was smallest in the moderate obstructive pattern group.

CONCLUSION

Voice parameters showed significant improvement after IL in both normal and mild obstructive pattern groups, but MPT and VHI did not significantly improve in the moderate obstructive pattern group. In addition, patients with normal pulmonary function had marked improvement of subjective symptoms after IL in comparison with patients with abnormal pulmonary function.

Respiratory and voice outcomes of office-based injection laryngoplasty in patients with unilateral vocal fold paralysis

Background

Injection laryngoplasty is a surgical procedure used in management of glottal insufficiency. The objective of this study was to assess respiratory and voice outcomes of office-based injection laryngoplasty in patients with unilateral vocal fold paralysis (UVFP). Ten patients underwent office-based injection via transcutaneous approach using Radiesse or hyaluronic acid. Auditory perceptual assessment (APA), voice handicap index (VHI), size of the glottic gap, acoustic parameters (jitter, shimmer, and harmonic to noise ratio), maximum phonation time (MPT), stroboscopic evaluation, pulmonary function tests (PFTs), and videofluoroscopic evaluation of swallowing were done pre-injection, 1 week and 3 months post-injection.

Results

Subjective and objective voice outcomes, in addition to laryngostroboscopic parameters improved after injection. Non-significant difference was found between pre- and post-injection results of the PFTs.

Conclusions

Office-based injection laryngoplasty is a safe and effective method for treating UVFP. Patients with glottic gap (< 1–3 mm) are perfect candidates for such procedure. Injection laryngoplasty improves patients’ voice quality and does not impair respiration.

Comparison of voice therapy and selective electrical stimulation of the larynx in early unilateral vocal fold paralysis after thyroid surgery: A retrospective data analysis

Objectives

The goal of the retrospective study was to investigate the 3‐month‐outcome after treatment of patients with early unilateral vocal fold paralysis (UVFP) with either standard voice therapy (VT) or selective electrical stimulation of the larynx (SES).

Design

Non‐randomised retrospective study.

Setting

1519 patients who underwent thyroid surgery between 2015 and 2018 were analysed according vocal fold mobility; UVFP patients were treated either by VT or SES.

Participants

51 UVFP patients.

Main outcome measures

51 UVFP patients have been advised regarding treatment options like either VT (group 1) or SES (group 2). The patients of group 1 (n = 26) and 2 (n = 25) were re‐assessed up to 3 months post‐operatively regarding UVFP persistence/recovery and perceptive voice sound quality. At follow‐ups, perceptual analysis of voice sound (using roughness=R/breathiness=B/hoarseness=H scale) and endoscopic laryngoscopy have been performed. Position of immobile vocal fold, shape of glottal closure and RBH parameters have been considered for statistical analyses.

Results

Restitution of UVFP with regular respiratory vocal fold mobility of both vocal folds occurred in 53.8% of group 1 (VT), and in 40.0% of group 2 (SES) after 3 months of therapy between both groups. No difference could be seen for RBH, type of glottal closure and position of ailing vocal folds in patients with persisting UVFP within both groups and between the groups.

Conclusions

The study reveals that SES can achieve similar functional outcome in early UVFP. Thus, it should be considered as an equivalent therapy alternative to VT for treatment of early UVFP patients since no significant difference in vocal outcome and glottal configuration between the two groups could be demonstrated.

Early voice therapy for unilateral vocal fold paralysis improves subglottal pressure and glottal closure

PURPOSE

In cases of unilateral vocal fold paralysis (UVFP), voice disorders caused by glottic insufficiency can lead to a considerable reduction in the patient's quality of life. Voice therapy (VT) is an effective treatment that must be started early after the onset of vocal fold paralysis. This study examined the effect of early VT for patients with UVFP occurring after esophagectomy.

MATERIALS AND METHODS

Patients who had residual UVFP at 1 month postoperatively after esophagectomy for esophageal cancer between November 2014 and March 2017 were evaluated. Seventeen patients were divided into the VT group (n = 6) and non-VT group (n = 11). We compared these two groups and retrospectively examined the effect of early VT. The study endpoints included aerodynamic tests, laryngeal endoscopy, laryngeal stroboscopy, and glottal closure. All of these evaluations were performed at preoperatively and at 1 and 3 months postoperatively.

RESULTS

Subglottal pressure reduced notably in the VT group, and both the mean flow rate and maximum phonation time tended to improve after VT. Conversely, there were no significant differences in MFR and MPT in the non-VT group. Furthermore, although UVFP remained after VT, we achieved glottal closure for all three patients. Conversely, only two of the six patients with glottic insufficiency in the non-VT group achieved glottal closure.

CONCLUSION

VT may be effective for improving impaired vocal function in patients with UVFP. It is reasonable to expect that VT can be initiated 1 month after the onset of vocal fold paralysis.

Gore-Tex implant extrusion following revision medialization thyroplasty: Case report and review of the literature

OBJECTIVE

To review current literature and experience with Gore-TexⓇ implant extrusion following medialization thyroplasty, as well as to report the unique case of Gore-TexⓇ implant extrusion following revision medialization thyroplasty.

METHODS

Review of existing literature and description of personal experience with unique case of Gore-TexⓇ implant extrusion following revision medialization thyroplasty.

RESULTS

Review of existing literature found no prior reported cases of Gore-TexⓇ implant extrusion following revision medialization thyroplasty. Risk factors for implant extrusion include the pressure of the implant on insertion and the inability to secure the implant. Cases of implant extrusion can be managed operatively via an endoscopic or via an external open approach.

CONCLUSION

This is the first reported case of Gore-TexⓇ implant extrusion following revision medialization thyroplasty. Careful consideration should be given in revision medialization thyroplasty as additional implant material may cause increased pressure, a risk factor for implant extrusion.

Selective vagus-recurrent laryngeal nerve anastomosis in thyroidectomy with cancer invasion or iatrogenic transection

PURPOSE

Immediate recurrent laryngeal nerve (RLN) reconstruction at the time of thyroid cancer extirpation can provide excellent postoperative phonatory function. This study is to present our experience with the methods of RLN reconstruction, and to evaluate the role of selective vagus to RLN anastomosis (SVR) in thyroidectomy.

METHODS

Respective review of RLN reconstruction in thyroid surgery from January 2004 to October 2018 was conducted in two tertiary referral academic medical centers. Immediate RLN reconstruction was performed for primary thyroidectomy patients with intraoperative nerve tumor invasion or iatrogenic transection. Laryngofiberoscopic examination, voice evaluation of maximum phonation time, and GRBAS scale were performed preoperatively, on the second day after surgery, and monthly postoperatively for the first year.

RESULTS

A total of 37 patients were enrolled. Twenty-nine RLNs were resected caused by tumor-associated trauma; the other nerves were inadvertently transected. Direct anastomosis (DA) was performed in eight patients, free nerve graft (FNG) was performed in four patients, ansa cervicalis to RLN anastomosis (ARA) was performed in eight patients, and SVR was performed in 17 patients. The mean periods from the reinnervation surgery of DA, SVR, ARA, and FNG to the phonation recovery were 46 ± 19 (days), 41 ± 29 (days), 83 ± 21 (days), and 137 ± 32 (days), respectively. There were improvements in the GRBAS scale of perceptual voice quality at 1 month for DA and SVR, 2months for ARA.

CONCLUSIONS

Intraoperative SVR reinnervation demonstrated voice improvement postoperatively and might be an effective treatment for thyroidectomy-related permanent unilateral vocal cord paralysis.

Efficacy of speech language therapy intervention in unilateral vocal fold paralysis - a systematic review and a meta-analysis of visual-perceptual outcome measures

OBJECTIVE

Unilateral vocal folds paralysis is a disorder that affects a patient's quality-of-life by disturbing their phonation, breathing, and swallowing activities. This systematic review aimed to estimate the efficacy of voice treatment on the vocal fold motility in adult patients with unilateral vocal folds paralysis.

METHODS

PubMed, CINAHL, CENTRAL, and Web of Science were searched for retrospective and prospective cohort, case-control, and cross-sectional with comparative studies with adults that were published between 1 January 2008 to 31 December 2018. After applying the inclusion and exclusion criteria a total of 10 studies containing morpho-functional evaluation results were included in the analysis. Pooled data analysis of the motility of the vocal folds before and after voice therapy allowed inferring about the efficacy of voice therapy intervention in patients with unilateral vocal folds paralysis. A random-effect model was used to estimate the effect size. Publication bias was considered.

RESULTS

The pooled data analysis of the visual-perceptual measures revealed that vocal fold motility improved in 72% (95% CI: 64.0-80.0) of all patients after the therapeutic interventions. The inconsistency index (I² = 18.35%) of the studies included in this meta-analysis revealed an extremely low heterogeneity. Funnel plot and Cochran's Q test showed no publication bias. The systematic review was limited to only English language articles.

CONCLUSION

This meta-analysis supports the evidence that voice therapy intervention can have a positive effect on the vocal fold motility, that is, they can improve the glottal gap closure, irrespective of the exercises and techniques used.

Nonselective Laryngeal Reinnervation versus Type 1 Thyroplasty in Patients with Unilateral Vocal Fold Paralysis: A Single Tertiary Centre Experience

OBJECTIVE

This study compared the voice outcomes of selected patients with unilateral vocal fold palsy (UVFP) who underwent either nonselective laryngeal reinnervation (LR) or Type 1 thyroplasty (thyroplasty) in a Malaysian tertiary centre using multidimensional voice assessments.

PARTICIPANTS

The study included 16 patients with UVFP who underwent either LR (9 patients) or thyroplasty (7 patients) between 2015 and 2018 who fulfilled the inclusion criteria.

MAIN OUTCOME MEASURES

The outcomes were measured subjectively and objectively with: (1) voice handicap index-10 (VHI-10- Malay version); (2) auditory perceptual evaluation using the breathiness component of Grade, Roughness, Breathiness, Asthenia, Strain scale; (3) maximum phonation time (MPT); and (4) acoustic analysis (jitter%, shimmer%, and NHR) using OperaVOX^TM. The outcomes were measured at baseline, 6 and 12-months postoperative. The comparison of outcomes between pre and postoperative of each group was evaluated using one-way ANOVA test. Mann-Whitney test was used to compare the outcomes between the two groups.

RESULTS

Comparison of each group at different time points showed significant improvement of VHI-10 and MPT of LR group between baseline and 12 months (P ≤ 0.05) whereas, the improvement in thyroplasty group was observed at all time points (P ≤ 0.05). When comparing between the two groups at 12 months, the VHI-10 and MPT was significantly better in the LR group than thyroplasty group with P = 0.004 and P = 0.001 respectively. Other outcome measures did not reveal significant difference between the two groups.

CONCLUSION

This observational study showed that LR may be better than thyroplasty in improving VHI-10 and MPT in selected patients with UVFP.

Injectable Silk-Based Hydrogel as an Alternative to Cervical Cerclage: A Rabbit Study

Background: Preterm birth is a common cause of morbidity and mortality in newborn infants. Cervical insufficiency (CI) is a significant cause of preterm birth. The treatment for CI is cerclage, which is a suture placed around the cervix to provide mechanical support. Cerclage, however, is associated with limited efficacy. Here we present an injectable, silk-based hydrogel as an alternative to cerclage. Objective: Pregnant rabbits were used as an animal model of pregnancy to study the mechanical properties, biocompatibility, and degradation of the hydrogel after cervical injection. Study Design: Silk hydrogel (200 μL volume) was injected into the cervix. Controls were either injected with saline or treated with cerclage (5-0 polyethylene terephthalate suture). To study the effect on mechanical properties, the cervix was tested in compression. Biodegradation of the hydrogel was followed over 6 weeks. For biocompatibility, expression levels of proinflammatory mediators were studied. Results: Hydrogel injection resulted in significant tissue augmentation-the cross-sectional area of the cervix increased 46.3 ± 3.0%. The modulus of the uninjected and hydrogel-injected tissues was 3.3 ± 0.7 and 3.2 ± 0.5 kPa at 5-10% strain, respectively (p = 0.8). Histology showed a mild inflammatory response surrounding the hydrogel. Biodegradation of the hydrogel showed 70% volume loss over 6 weeks. Hydrogel-injected tissue showed similar inflammatory response compared with cerclage. Conclusions: In pregnant rabbits, cervical injection of the silk-based hydrogel was biocompatible and naturally degraded. No adverse effects on timing of delivery and pup viability were seen. Silk-based hydrogels show promise for tissue augmentation during pregnancy. Impact Statement This research describes the use of injectable silk-based hydrogel for augmenting cervical tissue in vivo in a pregnant rabbit model. Further preclinical development of the methods and insights described in this article can lead to therapeutic use of this hydrogel as an alternative to cerclage in preterm birth due to cervical insufficiency.

Recurrent laryngeal nerve transection in mice results in translational upper airway dysfunction

The recurrent laryngeal nerve (RLN) is responsible for normal vocal-fold (VF) movement, and is at risk for iatrogenic injury during anterior neck surgical procedures in human patients. Injury, resulting in VF paralysis, may contribute to subsequent swallowing, voice, and respiratory dysfunction. Unfortunately, treatment for RLN injury does little to restore physiologic function of the VFs. Thus, we sought to create a mouse model with translational functional outcomes to further investigate RLN regeneration and potential therapeutic interventions. To do so, we performed ventral neck surgery in 21 C57BL/6J male mice, divided into two groups: Unilateral RLN Transection (n = 11) and Sham Injury (n = 10). Mice underwent behavioral assays to determine upper airway function at multiple time points prior to and following surgery. Transoral endoscopy, videofluoroscopy, ultrasonic vocalizations, and whole-body plethysmography were used to assess VF motion, swallow function, vocal function, and respiratory function, respectively. Affected outcome metrics, such as VF motion correlation, intervocalization interval, and peak inspiratory flow were identified to increase the translational potential of this model. Additionally, immunohistochemistry was used to investigate neuronal cell death in the nucleus ambiguus. Results revealed that RLN transection created ipsilateral VF paralysis that did not recover by 13 weeks postsurgery. Furthermore, there was evidence of significant vocal and respiratory dysfunction in the RLN transection group, but not the sham injury group. No significant differences in swallow function or neuronal cell death were found between the two groups. In conclusion, our mouse model of RLN injury provides several novel functional outcome measures to increase the translational potential of findings in preclinical animal studies. We will use this model and behavioral assays to assess various treatment options in future studies.

Medical and Surgical Advances in the Treatment of Unilateral Vocal Fold Paralysis

Purpose

In this chapter, unilateral vocal fold paralysis is described, and treatment options are discussed with emphasis on recent developments in treatment.

Conclusion

Unilateral vocal fold paralysis is a disorder commonly encountered by otolaryngologists and speech-language pathologists alike and is caused by dysfunction of one of the recurrent laryngeal nerves leading to dysphonia and dysphagia. The etiology of this disorder can include malignancy, iatrogenic injury, or traumatic injury or may be due to idiopathic causes, and evidence has suggested that the rates of different etiologies have changed over time. Treatment options include a variety of approaches and range from expectant management, voice therapy, as well as surgical and procedural approaches. Surgical approaches generally aim to augment the affected vocal fold to medialize its position, thereby reducing glottic insufficiency, and can include injection laryngoplasty and laryngeal framework surgery. Recurrent laryngeal nerve reinnervation is also an option for certain patients and can improve vocal fold bulk by restoring basal neurologic stimulation. Though it is a well-described phenomenon, with new developments in procedural interventions, unilateral vocal fold paralysis remains a dynamic entity in the field.

Perspectives on voice treatment for unilateral vocal fold paralysis

PURPOSE OF REVIEW

Unilateral vocal fold paralysis (UVFP) is a common cause of neurogenic dysphonia resulting in glottal insufficiency. To restore glottal sufficiency and reduce the presenting dysphonia, treatment involving either surgical intervention, voice therapy or a combination of the two is typically provided. Currently, there is no consensus for the most effective voice treatment for UVFP. This results in an inability to compare current studies, and a lack of treatment effectiveness for the management of UVFP. This study aims to review the most recent literature for the management of dysphonia due to UVFP to establish the current evidence base for voice treatment options.

RECENT FINDINGS

There was found to be a lack of consistency in the rationale, selection and timing of the surgical intervention and/or voice therapy being provided for patients with UVFP.

SUMMARY

Further consensus is required for the rationale and selection of voice treatment prescriptions for the management of UVFP in order to improve treatment effectiveness and voice outcomes in patients with UVFP.

Multidimensional effects of voice therapy in patients affected by unilateral vocal fold paralysis due to cancer

Introduction

Patients with unilateral vocal fold paralysis may demonstrate different degrees of voice perturbation depending on the position of the paralyzed vocal fold. Understanding the effectiveness of voice therapy in this population may be an important coefficient to define the therapeutic approach.

Objective

To evaluate the voice therapy effectiveness in the short, medium and long-term in patients with unilateral vocal fold paralysis and determine the risk factors for voice rehabilitation failure.

Methods

Prospective study with 61 patients affected by unilateral vocal fold paralysis enrolled. Each subject had voice therapy with an experienced speech pathologist twice a week. A multidimensional assessment protocol was used pre-treatment and in three different times after voice treatment initiation: short-term (1–3 months), medium-term (4–6 months) and long-term (12 months); it included videoendoscopy, maximum phonation time, GRBASI scale, acoustic voice analysis and the portuguese version of the voice handicap index.

Results

Multiple comparisons for GRBASI scale and VHI revealed statistically significant differences, except between medium and long term (p < 0.005). The data suggest that there is vocal improvement over time with stabilization results after 6 months (medium term). From the 28 patients with permanent unilateral vocal fold paralysis, 18 (69.2%) reached complete glottal closure following vocal therapy (p = 0.001). The logistic regression method indicated that the Jitter entered the final model as a risk factor for partial improvement. For every unit of increased Jitter, there was an increase of 0.1% (1.001) of the chance for partial improvement, which means an increase on no full improvement chance during rehabilitation.

Conclusion

Vocal rehabilitation improves perceptual and acoustic voice parameters and voice handicap index, besides favor glottal closure in patients with unilateral vocal fold paralysis. The results were also permanent during the period of 1 year. The Jitter value, when elevated, is a risk factor for the voice therapy success.

Symptomatic unilateral vocal fold paralysis following cardiothoracic surgery

PURPOSE

Unilateral vocal fold paralysis (UVFP) is a complication associated with cardiothoracic procedures that presents clinically as dysphonia and/or dysphagia with or without aspiration. The literature lacks both data on recovery of mobility and consensus on best management. Herein, our goals are to 1) Identify cardiothoracic procedures associated with symptomatic UVFP at our institution; 2) Review timing and nature of laryngology diagnosis and management; 3) Report spontaneous recovery rate of vocal fold mobility.

MATERIALS AND METHODS

Retrospective case series at single tertiary referral center between 2002 and 2015. 141 patients were included who underwent laryngology interventions (micronized acellular dermis injection laryngoplasty and/or type 1 thyroplasty) to treat symptomatic UVFP diagnosed subsequent to cardiothoracic surgery.

RESULTS

Pulmonary procedures were most often associated with UVFP (n=50/141; 35.5%). 87.2% had left-sided paralysis (n=123/141). Median time to diagnosis was 42days (x¯=114±348). Over time, UVFP was diagnosed progressively earlier after cardiothoracic surgery. 63.4% of patients (n=95/141) underwent injection laryngoplasty as their initial intervention with median time from diagnosis to injection of 11days (x¯=29.6±54). 41.1% (n=58/141) ultimately underwent type 1 thyroplasty at a median of 232.5days (x¯=367±510.2) after cardiothoracic surgery. 10.2% (n=9/88) of those with adequate follow-up recovered full vocal fold mobility.

CONCLUSIONS

Many cardiothoracic procedures are associated with symptomatic UVFP, predominantly left-sided. Our data showed poor recovery of vocal fold mobility relative to other studies. Early diagnosis and potential surgical medialization is important in the care of these patients.

Medialisation thyroplasty with tensor fascia lata: a novel approach for reducing post-thyroplasty complications

BACKGROUND

Medialisation thyroplasty is considered the 'gold standard' treatment for unilateral vocal fold paralysis, enabling improvement of voice and swallowing function, and preventing life-threatening aspiration events. The most commonly used laryngeal implants induce some degree of local tissue inflammatory response, and carry the risk of immediate or delayed implant extrusion.

METHODS

This paper describes a novel approach for medialisation thyroplasty. Specifically, it utilises a ribbon of autologous tensor fascia lata harvested at the time of surgery. This is layered within the paraglottic space in a manner similar to Gore-Tex thyroplasty.

RESULTS

Thus far, this method has been accomplished in two patients with unilateral vocal fold paralysis, who also received prior radiotherapy to the head and neck.

CONCLUSION

Given the increased risk of post-operative wound breakdown and infection in irradiated patients, it is suggested that this new approach will lead to improved outcomes, and a decrease in complications such as extrusion or wound infection, particularly in this patient population.

Factors Predicting the Recovery of Unilateral Vocal Fold Paralysis After Thyroidectomy

BACKGROUND

We used voice analysis and clinicopathological factors to explore the prognosis of unilateral vocal fold paralysis after thyroid surgery.

METHODS

The medical records of 63 females who developed unilateral vocal fold paralysis after thyroidectomy were reviewed. All patients were divided into two groups: those who recovered from vocal fold paralysis and those who did not. We analyzed clinical parameters and voice analysis results in a search for correlations with recovery from paralysis.

RESULTS

Of the 63 patients, 37 (58%) recovered from paralysis. A small tumor size, incomplete paralysis, the absence of arytenoid tilting, no compensatory movement of the normal side, lower postoperative shimmer, a higher postoperative maximum phonation time (MPT), and lower postoperative subglottic pressure correlated significantly with recovery from vocal fold paralysis. Multivariate analysis confirmed that the absence of compensatory movement of the normal side on videostroboscopy was independently prognostic. A postoperative MPT of 6.86 appeared to be optimal for prediction of recovery. Most patients recovered within 6 months, but those with incomplete paralysis recovered about 3 months earlier. At the 12-month follow-up, the thyroidectomy-related voice questionnaire scores had returned to preoperative values in only 12 patients (19.0%); 51 patients (81.0%) did not fully recover.

CONCLUSION

Compensatory movement of the normal side evident on videostroboscopy was a poor prognostic factor. Voice analysis can be helpful in counseling vocal fold paralysis patients after thyroidectomy, and early intervention may be considered in patients who are expected to have a poor prognosis.

Indications for Direct Laryngoscopic Examination of Vocal Cord Function Prior to Anterior Cervical Surgery

Recurrent laryngeal nerve palsy (RLNP) is among the most common complications in both thyroid surgeries and anterior approaches to the cervical spine, having both a diverse etiology and presentation. Most bilateral paresis, with subsequent devastating impact on patients, are due to failure to recognize unilateral recurrent laryngeal nerve paralysis and, although rare, are entirely preventable with appropriate history and screening. Recurrent laryngeal nerve palsy has been shown to present asymptomatically in as high as 32% of cases, which yields limitations on exclusively screening with physical examination. Based on the available literature, diagnosis of unilateral RLNP is the critical factor in preventing the occurrence of bilateral RLNP as the surgeon may elect to operate on the injured side to prevent bilateral paresis. Analysis of incidence rates shows postoperative development of unilateral RLNP is 13.1 (95% confidence interval [CI]: 6.1-28.1) and 13.90 (95% CI: 6.6-29.3) times more likely in anterior spine and thyroid surgery, respectively, in comparison with intubation. Currently, there is no consensus on when to order a preoperative laryngoscopic examination prior to anterior cervical spine surgery. The importance of patient history should be emphasized, as it is the basis for indications of preoperative laryngoscopy. Efforts to minimize postoperative complications must be made, especially when considering the rising rate of cervical fusion. This study presents a systematic review of the literature defining key causes of RLNP, with a probability-based protocol to indicate direct laryngoscopy prior to anterior cervical surgery as a screening tool in the prevention of bilateral RLNP.

[On the problem of voice rehabilitation in the case of unilateral vocal fold paresis]

BACKGROUND

Unilateral vocal fold paresis (UVFP) significantly deteriorates the patient's quality of life. The leading role in the rehabilitation of the patients presenting with UVFP belongs to stimulation therapy which consists in the activation of muscle re-innervation of the larynx and the compensatory mechanisms allowing to achieve the most complete closure of the vocal folds during phonation.

AIM

The objective of the present study was the optimization of the conservative treatment of patients with UVFP.

MATERIAL AND METHODS

Fifty patients at the age varying from 18 to 70 years presenting with UVFP (the duration of the disease less than 6 months underwent the comprehensive treatment including electrostimulation of the larynx, vitamin therapy, and speech therapy. The patients were divided into two groups: A and B comprised of 25 subjects each. Those of Group A were given, in addition to the standard treatment, a 1.5 month-long course of Neuromidin therapy. The results of the treatment were evaluated with the use of laryngostroboscopy, flowmetry, the GRBAS scale, acoustic voice analysis (lingWaves), and the VHI questionnaire.

RESULTS

The restoration of vocal fold mobility was achieved in 20% and 8% of the patients of groups A and B respectively. The clinical effect was absent in 12% of the patients in Group A and 28% of the patients in Group B. The differences between groups were statistically significant (p<0.05). In the remaining cases, the positive dynamics of the flowmetric characteristics, GRBAS and VHI data, maximum phonation time, Jitter, DSI, frequency and dynamic ranges as well as the intensity of voice were documented in 68% of patients in Group A and 64% of patients in Group B).

CONCLUSION

The results of the study confirm the usefulness of the combined treatment of UVFP consisting of electrostimulation of the larynx together with speech therapy and application of cholinergic drugs. The addition of Neuromidin to the conventional scheme of conservative treatment can further improve its efficiency from 72% to 88%.

Laboratory Evaluation of Vocal Fold Paralysis and Paresis

OBJECTIVES

This study aimed to assess the value of comprehensive laboratory evaluation in patients with vocal fold paralysis or paresis.

STUDY DESIGN

This is a retrospective chart review.

METHODS

Records of 231 patients with vocal fold paralysis or paresis were reviewed to determine whether there is a significant increase in the number of abnormal test results compared with rates of abnormal results for these tests in the general population and whether testing resulted in clinically important diagnosis. Laboratory data were collected from charts from initial visits from 2010 to 2014 and compared with national data.

RESULTS

When controlled for age and sex, white blood cell count was found to have a significantly higher rate of abnormal test results (P < 0.001) in patients with vocal fold paralysis or paresis than the general population. Although hemoglobin, thyroid-stimulating hormone, and thyroid antibody tests were more likely to be abnormal in our patient population, the trend was not statistically significant. Further, the prevalence of syphilis and myasthenia gravis was found to be higher in these subjects than their respective national prevalences, and the incidence of Lyme disease was found to be higher than the national prevalence of Lyme disease. Several patients were diagnosed with medically important conditions such as diabetes, thyroid dysfunction, syphilis, myasthenia gravis, and Lyme disease based on these tests.

CONCLUSION

This study suggests that comprehensive testing of patients with vocal fold movement disorders results in diagnoses that would be missed without a comprehensive evaluation, some of which are important medically, although their causal relationship to vocal fold paralysis or paresis was not investigated or established.

Shape of Thyroid Cartilage Influences Outcome of Montgomery Medialization Thyroplasty: A Gender Issue

OBJECTIVE

This study aimed to determine whether the shape of the thyroid cartilage and gender influence voice outcomes after a Montgomery thyroplasty implant system (MTIS).

METHODS

A retrospective cohort study was performed on 20 consecutive patients who underwent MTIS. Voice outcome variables were the relative decrease in Voice Handicap Index (%) and the absolute increase in maximum phonation time (MPT) (in seconds). Material variables were the angle between the thyroid cartilage laminae (α-angle), the size of the prosthesis, and a combination of both (the α-ratio). Continuous variables were analyzed using medians and were compared between groups using the Mann-Whitney U test. Factors associated with the outcome variables were assessed by multivariable linear regression. A Pearson coefficient was calculated between material variables.

RESULTS

The absolute increase in MPT between the pre- and postoperative period was significantly different between men and women, with a median absolute increase of 11.0 seconds for men and of 1.3 seconds for women (P < 0.001). A strong inverse correlation between the α-ratio and the absolute increase in MPT is observed in all patients, with a Pearson correlation coefficient R = -0.769 (P < 0.001). No factors were significantly associated with the relative Voice Handicap Index decrease in univariable or multivariable analyses. A better Pearson coefficient between the α-angle and the prosthesis size was found for females (0.8 vs 0.71).

CONCLUSION

The MTIS is a good thyroplasty modality for male patients, but inadequate design of MTIS female implants leads to poor MPT outcomes. This represents a gender issue that needs to be further studied and eventually tackled.

Unilateral True Vocal Fold Paralysis: Cause of Right-Sided Lesions

At the Georgetown University Center for the Voice, 778 patients were referred for evaluation between July 1, 1990, and June 30, 1995. During this 5-year period, right true vocal fold paralysis or paresis was diagnosed in 24 of these patients (3%). Videostroboscopy, voice analysis, and patient records were reviewed. Ages ranged from 23 to 80 years, and sex distribution approximated a 1:1 ratio. The patients presenting symptoms included hoarseness, dysphagia, choking, voice pitch change, voice weakness, fatigability, and breathiness. Sources of the vocal fold dysfunction included iatrogenic, traumatic, central, and infectious causes.

Unilateral Vocal Cord Paralysis Causes Contralateral False-Positive Positron Emission Tomography Scans of the Larynx

Positron emission tomography (PET) is used in the management of head and neck cancers. It identifies tissue with increased metabolic activity and is not specific for malignancy. A false-positive PET scan of the larynx is associated with vocal cord paralysis. We reviewed PET scan reports of patients with lung cancer from 1998 to 2001 to identify patients with increased 18-fluoro-2-deoxyglucose uptake in the larynx without a known history of head and neck cancer and then correlated this increased uptake with laryngoscopic findings. There were 17 patients who had a positive PET finding in the larynx. Fifteen of those had a false-positive PET scan in the larynx. All had contralateral vocal cord paralysis. Two patients were noted to have head and neck cancer. We conclude that vocal cord paralysis can cause a false-positive PET scan on the contralateral side of the larynx due to overactivity of laryngeal muscles that compensate for the paralyzed cord.

Polydimethylsiloxane Particles for Permanent Injection Laryngoplasty

Objectives:

Polydimethylsiloxane (PDMS) particles are a nonresorbable material that allows for permanent vocal fold augmentation. This study investigated morbidity and voice quality in patients treated for unilateral vocal fold paralysis by injection of PDMS particles.

Methods:

Fourteen patients who had neurogenic unilateral vocal fold paralysis of different causes were included in this prospective study. Each patient underwent videostroboscopic assessment before and after operation. Friedrich's dysphonia index (DI), a score system combining subjective and objective parameters, was used to describe voice quality. A DI of 0 reflects a normal voice, and a DI of 3 stands for complete aphonia. The PDMS particles were injected into the paraglottic space by microlaryngoscopy under general anesthesia.

Results:

The median follow-up was 4.1 months. There was no complication attributable to the injection of PDMS particles. The mean DI was 2.8 before operation. After the operation, voice quality improved significantly in each patient, as reflected by a mean postinjection DI of 1.4.

Conclusions:

Particles of PDMS provide a relatively safe and minimally invasive option for permanent vocal fold augmentation. The functional results in terms of voice improvement are comparable to those obtained with other techniques, including thyroplasty. In the European Community, PDMS particles are officially approved for use in the human larynx.

Medialization thyroplasty for cancer-related unilateral vocal fold paralysis

Objective

To justify the application of medialization thyroplasty in Chinese patients with symptomatic cancer-related unilateral vocal fold paralysis (UVFP).

Study Design and Setting

Retrospective chart review from February 2000 to March 2006.

Results

Eighty-seven Chinese patients undergoing medialization thyroplasty for UVFP were included; there were no significant differences between the cancer-related and benign groups in terms of the speech and swallowing rehabilitation outcome and the perioperative complication rate ( P > 0.05). The median survival time of cancer-related UVFP patients from the date of medialization to death was 129 days. Age more than 65 years was identified as the only factor for a shorter survival period after medialization ( P = 0.040).

Conclusion

Medialization thyroplasty restores satisfactory speech and swallowing and has a low perioperative complication rate in Chinese patients with cancer-related UVFP. Postmedialization survival period was also reasonable.

Significance

Medialization thyroplasty is a justifiable treatment option for cancer-related UVFP.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Augmentation Autologous Adipose Injections in the Larynx

OBJECTIVE

Autologous adipose injection (AAI) is a recognized method for vocal fold augmentation. The study's purpose is to explore short- and long-term outcomes of AAI.

METHODS

Retrospective chart review of 43 patients undergoing AAI was performed; patient perception of outcome, Voice Handicap Index (VHI), maximum phonatory time (MPT), and disposition were evaluated.

RESULTS

Over 5 years, 43 AAI patients had documented postoperative follow-up (25 paralysis, 8 paresis, 9 bowing/presbylarynges, and 5 scar/sulci). Mean follow-up was 32 weeks. There was gradual patient loss to follow-up. Thirty-nine of 40 (98%) had patient-reported improvement at 6 weeks, 28 of 34 (82%) had improvement at 2 to 6 months, with 10 of 12 (83%) sustaining their improvement for >1 year. Significant improvement in mean VHI was observed at 4 to 6 weeks (mean reduction, 26; P < .0001) and 2 to 6 months (mean reduction, 23; P < .0001). Improvement in mean MPT was observed at 4 to 6 weeks (mean increase, 8 s; P < .0001), 2 to 6 months (6 s; P = .007), and >1 year (4 s; P = .03). Eight patients went on to medialization laryngoplasty.

CONCLUSION

AAI successfully augments vocal folds in short-term outcomes with some gradual decrease in effectiveness. Although patient attrition limited conclusions, objective long-term benefit may occur in >50% of patients.

Effect on laryngeal adductor function of vincristine block of posterior cricoarytenoid muscle 3 to 5 months after recurrent laryngeal nerve injury

OBJECTIVES

It has been shown in a canine model that a single injection of vincristine into the posterior cricoarytenoid (PCA) muscle at the time of recurrent laryngeal nerve (RLN) injury effectively blocks its reinnervation and results in improved adductor strength. But clinically, such injuries are usually diagnosed weeks or months after onset. Vincristine injection does not affect a muscle that is already innervated; thus, there is a limited time frame following RLN injury during which a vincristine injection could effectively improve ultimate laryngeal adductor functional recovery. A series of delayed injections was performed in a canine model and results assessed.

STUDY DESIGN

Animal (canine) experiment.

METHODS

The RLN was transected and repaired, and vincristine (0.4 mg) was injected into the PCA muscle at the time of injury (n=12) or 3, 4, and 5 months later (n=8 each study group). Six months after RLN injury, laryngeal adductor function was measured. Results of vincristine injection without RLN injury (n=6) and longer-term (12 months) follow-up for time zero injections (n=4) are also reported.

RESULTS

The animals injected at time zero had better adductor function than non-injected controls, as reported previously, and this result was further increased at 12 months. The 3-month delay gave results similar to the time zero group. The 5-month delay group showed no vincristine benefit, and the 4-month delay group gave an intermediate result. Vincristine to the PCA had no effect on adductor function when the RLN was left intact. Plasma levels showed 19% of injected vincristine reached systemic circulation, which was cleared within 69 hours.

CONCLUSIONS

Vincristine injection of the PCA muscle after RLN injury, which blocks this antagonist muscle from synkinetic reinnervation, leads to improved laryngeal adductor functional recovery. The window of opportunity to apply this treatment closes by 4 months after RLN injury in the canine model. Human RLN recovery follows a similar time course and can reasonably be expected to have a similar therapeutic window.

Laryngeal Reinnervation Featuring Refined Nerve-Muscle Pedicle Implantation Evaluated via Electromyography and Use of Coronal Images

Objective

To evaluate the long-term efficacy of laryngeal reinnervation via refined nerve-muscle pedicle (NMP) flap implantation combined with arytenoid adduction to treat unilateral vocal fold paralysis (UVFP), employing laryngeal electromyography (LEMG), coronal imaging, and phonatory function assessment.

Study Design

Case series with chart review.

Setting

University hospital.

Subjects and Methods

We retrospectively reviewed 12 UVFP patients who underwent refined NMP implantation with arytenoid adduction. Videostroboscopy, phonatory functional analysis, LEMG, and coronal imaging were performed before and 2 years after surgery. In LEMG analysis, a 4-point scale was employed to grade motor unit (MU) recruitment: 4+ reflected no recruitment, 3+ greatly decreased recruitment, 2+ moderately decreased recruitment, and 1+ mildly decreased activity, associated with less than the full interference pattern. Coronal images were assessed in terms of differences in thickness and the vertical positions of the vocal folds.

Results

Phonatory function improved significantly after operation in all patients. In terms of LEMG findings, the preoperative MU recruitment scores were 1+ in no patients, 2+ in 4 patients, 3+ in 1 patient, and 4+ in 7 patients. Postoperative MU recruitment results were 1+ in 6 patients, 2+ in 5 patients, 3+ in 1 patient, and 4+ in no patients. Thinning of the affected fold during phonation was evident preoperatively in 9 of 10 patients. The affected and healthy folds were equal in volume in 4 of 9 patients postoperatively.

Conclusion

The LEMG findings and coronal imaging suggest that NMP implantation may have enabled successful reinnervation of the laryngeal muscles of UVFP patients.

Vocal fold paralysis: improved adductor recovery by vincristine blockade of posterior cricoarytenoid

OBJECTIVES/HYPOTHESIS

A new treatment for acute unilateral vocal-fold paralysis (UVFP) was proposed in which a drug is injected into the posterior cricoarytenoid muscle (PCA) shortly after nerve injury, before the degree of natural recovery is known, to prevent antagonistic synkinetic reinnervation. This concept was tested in a series of canine experiments using vincristine as the blocking agent.

STUDY DESIGN

Animal experiments.

METHODS

Laryngeal adductor function was measured at baseline and at 6 months following experimental recurrent laryngeal nerve (RLN) injuries, including complete transection, crush injury, and cautery. In the treatment animals, the PCA was injected with vincristine at the time of RLN injury.

RESULTS

Adductor function in the vincristine-treated hemilarynges was significantly improved compared with injury-matched noninjected controls (total n = 43). Transection/repair controls recovered 56.1% of original adductor strength; vincristine-treated hemilarynges recovered to 73.1% (P = 0.002). Cautery injuries also improved with vincristine block (60.7% vs. 88.7%; P = 0.031). Crush injuries recovered well even without vincristine (104.8% vs. 111.2%; P = 0.35).

CONCLUSION

These findings support a new paradigm of early, preemptive blockade of the antagonist muscle (PCA) to improve ultimate net adductor strength, which could potentially improve functional recovery in many UVFP patients and avoid the need for medialization procedures. Possible clinical aspects of this new approach are discussed.

Laryngeal muscle activity in unilateral vocal fold paralysis patients using electromyography and coronal reconstructed images

OBJECTIVE

To assess laryngeal muscle activity in unilateral vocal fold paralysis (UVFP) patients using laryngeal electromyography (LEMG) and coronal images.

STUDY DESIGN

Case series with chart review.

SETTING

University hospital.

SUBJECTS AND METHODS

Twenty-one patients diagnosed with UVFP of at least 6 months in duration with paralytic dysphonia, underwent LEMG, phonatory function tests, and coronal imaging. A 4-point scale was used to grade motor unit (MU) recruitment: absent = 4+, greatly decreased = 3+, moderately decreased = 2+, and mildly decreased = 1+. Maximum phonation time (MPT) and mean flow rate (MFR) were employed. Coronal images were assessed for differences in thickness and vertical position of the vocal folds during phonation and inhalation.

RESULTS

MU recruitment in thyroarytenoid/lateral cricoarytenoid (TA/LCA) muscle complex results were 1+ for 4 patients, 2+ for 5, 3+ for 6, and 4+ for 6. MPT was positively correlated with MU recruitment. Thinning of the affected fold was evident during phonation in 19 of the 21 subjects. The affected fold was at an equal level with the healthy fold in all 9 subjects with MU recruitment of 1+ and 2+. Eleven of 12 subjects with MU recruitments of 3+ and 4+ showed the affected fold at a higher level than the healthy fold. There was a significant difference between MU recruitment and the vertical position of the affected fold.

CONCLUSIONS

Synkinetic reinnervation may occur in some cases with UVFP. MU recruitments of TA/LCA muscle complex in UVFP patients may be related to phonatory function and the vertical position of the affected fold.

Vocal fold augmentation with injectable polycaprolactone microspheres/pluronic F127 hydrogel: long-term in vivo study for the treatment of glottal insufficiency

There is increasing demand for reconstruction of glottal insufficiency. Several injection materials have been examined for this purpose, but all had limitations, such as poor long-term durability, migration from the injection site, inflammation, granuloma formation, and interference with vocal fold vibration due to viscoelastic mismatch. Here, we developed a novel injection material, consisting of polycaprolactone (PCL) microspheres, which exhibits better viscoelasticity than conventional materials, and Pluronic F127 carrier, which decreases the migration of the injection materials. The material was injected into rabbits with glottal insufficiency and compared with the FDA-approved injection material, calcium hydroxylapatite (CaHA). Endoscopic and histological examinations indicated that PCL/Pluronic F127 remained at the injection site with no inflammatory response or granuloma formation, whereas CaHA leaked out and migrated from the injection site. Therefore, vocal fold augmentation was almost completely retained during the 12-month follow-up period in this study. Moreover, induced phonation and high-speed recording of vocal fold vibration showed decreased vocal fold gap area in the PCL/Pluronic F127 group. Our newly developed injection material, PCL/Pluronic F127, permits efficient augmentation of paralyzed vocal fold without complications, a concept that can be applied clinically, as demonstrated by the successful long-term follow-up.

Acquired unilateral vocal fold paralysis: retrospective analysis of a single institutional experience

Background:

Vocal cord paralysis continues to be an important issue in laryngology and is considered as a sign of underlying disease; the etiologies of this problem are varied and changing.

Aims:

The study was to carry out a retrospective analysis of patients with unilateral vocal fold paralysis diagnosed.

Materials and Methods:

The medical records of 53 patients diagnosed and treated for unilateral vocal fold paralysis were studied retrospectively. Data regarding age, sex, duration of symptoms, etiology, and side of paralysis were recorded.

Results:

Out of the 53 cases, 36 were females and 17 males with a ratio of 2.1:1. The age of the patients ranged from 17-75 years. In 18.9% the cause was idiopathic. Surgical trauma (iatrogenic) problems was the most encountered etiology (66%), others included malignancy (non laryngeal) (7.5%), central (3.8%), external neck trauma (1.9%) and radiation therapy 1.9%. Thyroid surgery was the most commonly reported neck surgery in 50.9%.

Conclusions:

Thyroidectomy continues to be the single most common surgical procedure responsible for unilateral vocal cord paralysis. For this reason, routine pre and postoperative laryngoscopy should be considered in all patients undergoing surgeries with a potential risk for recurrent nerve paralysis to reduce the postoperative morbidity.

The cost of vocal fold paralysis after thyroidectomy

OBJECTIVES/HYPOTHESIS

To determine the added cost of care and analyze risk factors in patients who suffered vocal fold paralysis (VFP) after thyroid surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Seventy-six patients who developed unilateral or bilateral VFP after thyroidectomy from 2005 through 2009, and a control group of 238 patients who underwent the same surgery without developing VFP, were compared on hospital charges, hospital and intensive care unit (ICU) length of stay (LOS), unplanned intubation, tracheotomies, respiratory failure, readmission, death, pathology, body mass index (BMI), gland weight, swallowing studies, and need for indwelling feeding tube. Differences between outcomes for unilateral VFP patients versus bilateral VFP patients were analyzed. Rate of recovery of VFP and need for further surgery after thyroidectomy were described.

RESULTS

Patients who developed VFP after thyroidectomy had significantly greater rates of all the parameters listed above. BMI, gland weight, and pathology (malignant vs. benign) were not significantly different between the two groups. VFP group underwent additional surgeries after thyroidectomy related to the VFP. Thirty-three% of unilateral VFP patients with long-term follow-up recovered fully. Patients with bilateral VFP with long-term follow-up, had recovery of one vocal fold in 50% and both in 23% of cases.

CONCLUSIONS

Patients with unilateral or bilateral VFP after thyroidectomy experience significantly more morbidity and incurred significantly more health care charges after surgery than similar patients who do not have VFP after thyroidectomy. The likelihood of VFP was not related to malignancy, BMI, or thyroid gland weight in this series.

Clinical Practice Guideline

Objective

Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts, suspicious findings on fine needle aspiration biopsy, dysphagia from cervical esophageal compression, or dyspnea from airway compression. About 1 in 10 patients experience temporary laryngeal nerve injury after surgery, with longer lasting voice problems in up to 1 in 25. Reduced quality of life after thyroid surgery is multifactorial and may include the need for lifelong medication, thyroid suppression, radioactive scanning/treatment, temporary and permanent hypoparathyroidism, temporary or permanent dysphonia postoperatively, and dysphagia. This clinical practice guideline provides evidence-based recommendations for management of the patient’s voice when undergoing thyroid surgery during the preoperative, intraoperative, and postoperative period.

Purpose

The purpose of this guideline is to optimize voice outcomes for adult patients aged 18 years or older after thyroid surgery. The target audience is any clinician involved in managing such patients, which includes but may not be limited to otolaryngologists, general surgeons, endocrinologists, internists, speech-language pathologists, family physicians and other primary care providers, anesthesiologists, nurses, and others who manage patients with thyroid/voice issues. The guideline applies to any setting in which clinicians may interact with patients before, during, or after thyroid surgery. Children under age 18 years are specifically excluded from the target population; however, the panel understands that many of the findings may be applicable to this population. Also excluded are patients undergoing concurrent laryngectomy. Although this guideline is limited to thyroidectomy, some of the recommendations may extrapolate to parathyroidectomy as well.

Results

The guideline development group made a strong recommendation that the surgeon should identify the recurrent laryngeal nerve(s) during thyroid surgery. The group made recommendations that the clinician or surgeon should (1) document assessment of the patient’s voice once a decision has been made to proceed with thyroid surgery; (2) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, if the patient’s voice is impaired and a decision has been made to proceed with thyroid surgery; (3) examine vocal fold mobility, or refer the patient to a clinician who can examine vocal fold mobility, once a decision has been made to proceed with thyroid surgery if the patient’s voice is normal and the patient has (a) thyroid cancer with suspected extrathyroidal extension, or (b) prior neck surgery that increases the risk of laryngeal nerve injury (carotid endarterectomy, anterior approach to the cervical spine, cervical esophagectomy, and prior thyroid or parathyroid surgery), or (c) both; (4) educate the patient about the potential impact of thyroid surgery on voice once a decision has been made to proceed with thyroid surgery; (5) inform the anesthesiologist of the results of abnormal preoperative laryngeal assessment in patients who have had laryngoscopy prior to thyroid surgery; (6) take steps to preserve the external branch of the surperior laryngeal nerve(s) when performing thyroid surgery; (7) document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery; (8) examine vocal fold mobility or refer the patient for examination of vocal fold mobility in patients with a change in voice following thyroid surgery; (9) refer a patient to an otolaryngologist when abnormal vocal fold mobility is identified after thyroid surgery; (10) counsel patients with voice change or abnormal vocal fold mobility after thyroid surgery on options for voice rehabilitation. The group made an option that the surgeon or his or her designee may monitor laryngeal electromyography during thyroid surgery. The group made no recommendation regarding the impact of a single intraoperative dose of intravenous corticosteroid on voice outcomes in patients undergoing thyroid surgery.

Laryngeal electromyography in dysphonic patients with incomplete glottic closure

The lack of specificity in laryngoscopical examination requires that the diagnosis of superior laryngeal and recurrent laryngeal nerve involvement be carried out with the aid of electromyography.

Objective

This study aims to assess the electrophysiological function of the superior and inferior laryngeal nerves by measuring the electrical activity of the muscles they innervate in dysphonic patients with incomplete closure of the vocal folds during phonation.

Method

Thirty-nine patients with incomplete glottic closure were enrolled in a prospective study and had their cricothyroid, thyroarytenoid, and lateral cricoarytenoid muscles examined bilaterally through electromyography. Insertion activity, electrical activity at rest (fibrillation, positive wave and fasciculation) and during muscle voluntary contraction (recruitment, amplitude, potential length and latency between electrical activity and phonation) were measured.

Results

No altered test results were observed for parameters insertion activity and electrical activity at rest. None of the patients had recruitment dysfunction. The mean electrical potential amplitude values were within normal range for the tested muscles, as were potential durations and latency times between the onset of electrical activity and phonation.

Conclusion

No signs of denervation were seen in the thyroarytenoid, cricothyroid, and lateral cricoarytenoid muscles of the studied patients.

Voice quality after recurrent laryngeal nerve resection and immediate reconstruction

OBJECTIVE

To evaluate clinician perception of voice quality, patient self-reported psychosocial impact of dysphonia, and glottic closure in patients who have undergone resection of the recurrent laryngeal nerve (RLN) and immediate operative reconstruction during thyroid surgery.

STUDY DESIGN

Prospective observational study.

SETTING

Single tertiary care hospital.

SUBJECTS AND METHODS

Nine patients underwent immediate operative reconstruction of the RLN by the senior author from 2002 to present. Outcome measures included (1) perceptual voice ratings assessed using the GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale, (2) psychosocial impact of dysphonia assessed using the Voice Handicap Index (VHI), and (3) assessment of glottic closure from laryngeal videostroboscopy.

RESULTS

The RLN was reconstructed with primary anastomosis (4), free nerve graft (3), or vagus-RLN anastomosis (2). Seven patients had voice samples and videostroboscopy examinations obtained at a minimum of 9 months from surgery. Six were judged to have slight disturbance of voice based on overall Grade scoring (G = 1). Five rated their voice as normal or mild on the VHI instrument (score range 8-29). Laryngeal analysis revealed the immobile vocal fold in the median, physiologic phonating position with preserved bulk, recovered tension, and glottic closure during phonation. Three patients less than 9 months from surgery had an expected severe self-reported rating of dysphonia.

CONCLUSION

Primary anastomosis, free nerve grafting, and vagus-RLN anastomosis are viable options for RLN reconstruction. Patients who undergo resection and immediate reconstruction of the RLN are able to regain self-perceived functional voices.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of Fibrin Glue on Collagen Deposition after Autologous Fascia Grafting in Rabbit Vocal Folds

Objectives:

Fibrin glue (FG) is a reaction product of fibrinogen and thrombin that forms a fibrin clot responsible for tissue adhesion. However, FG and its components may interfere with wound healing by interacting with cytokines such as transforming growth factor–β (TGF-β). The objective of this study was to investigate the effect of FG on collagen deposition after fascia grafting in the vocal folds of rabbits.

Methods:

Eighteen rabbits underwent autologous fascia grafting in both vocal folds, and the left side was fixed with FG. Each animal was painlessly sacrificed after 7, 30, or 90 days. The larynx was removed, and the vocal folds were prepared for histomorphometric analysis by picrosirius red staining to evaluate collagen deposition around the graft.

Results:

There was a significant increase in collagen density around the grafts at 90 days in the vocal folds that were fixed with FG (p = 0.0102) compared with the control vocal folds.

Conclusions:

Application of FG altered collagen deposition around the fascia grafts, leading to significantly increased collagen density after 90 days. Differences found in the composition of the extracellular matrix in later stages of the healing process are a result of changes that occur in the beginning of this process. Therapeutic interventions, such as the use of FG and/or its components, performed in the early stages of wound healing may interfere with the complex interactions of fibroblasts, inflammatory cells, and cytokines (especially TGF-β), thereby modulating the healing process.