"Finding a Voice": Imaging Features after Phonosurgical Procedures for Vocal Fold Paralysis

Type I Thyroplasty or Fat Injection Laryngoplasty Versus Arytenoid Adduction: Effects of Surgery on Voice Recovery in Patients With Unilateral Vocal Fold Paralysis

Objective: Type I (medialization) thyroplasty (MT), fat injection laryngoplasty (FIL), and arytenoid adduction (AA) are the 3 most common surgical treatments for unilateral vocal fold paralysis (UVFP). While MT and FIL involve medialization of the paralyzed vocal fold, the goal of AA is to reduce the glottal-level difference. The current study compared the effects of these surgical treatments on voice quality in patients with UVFP. Methods: This retrospective study included 87 patients with UVFP who underwent MT (n = 12), FIL (n = 31), AA (n = 6), or AA with MT (n = 38). Patients who underwent the former 2 surgical treatments were included in the thyroplasty (TP) group, while those who underwent the latter 2 were included in the AA group. Maximum phonation time (MPT), pitch period perturbation quotient (PPQ), amplitude perturbation quotient, and harmonic-to-noise ratio (HNR) were evaluated in all patients before and 1 month after surgery. Results: The TP group exhibited significant improvements in MPT (P < .001) and PPQ (P = .012), while the AA group exhibited significant improvements in all parameters (P < .001). Before surgery, voice quality was significantly worse in the AA group than in the TP group for all measures. However, there were no significant differences between the groups after treatment. Conclusion: Surgeries in both groups were effective for voice recovery in patients with UVFP under the appropriate surgical selection. Our results also highlight the importance of preoperative evaluation and the potential value of etiology for selecting the appropriate procedure.

Imaging of Treated Thyroid and Parathyroid Disease

The thyroid and parathyroid glands are endocrine structures located in the visceral space of the infrahyoid neck. Imaging plays a critical role in the evaluation of patients with thyroid cancer, both in the pre and posttreatment setting. Disorders of thyroid function, that is, hyperthyroidism and hypothyroidism, are also fairly common, although imaging utilization is less frequent with these conditions. Parathyroid dysfunction results in disordered calcium metabolism. Imaging is frequently applied in the preoperative assessment of these patients undergoing parathyroidectomy; however, routine imaging in the postoperative setting is uncommon. Parathyroid carcinoma is rare; however, imaging may be used in the pre and posttreatment setting.

Postoperative Pharynx and Larynx

Cancers of the pharynx and larynx are treated using a combination of chemotherapeutic, radiation, and surgical techniques, depending on the cancer type, biology, location, and stage, as well as patient and other factors. When imaging in the postsurgical setting, the knowledge of the type of tumor, preoperative appearance, and type of surgery performed is essential for accurate interpretation. Surgical anatomic changes, surgical implants/devices, and potential postsurgical complications must be differentiated from suspected recurrent tumors.

Surgical effects of type-I thyroplasty and fat injection laryngoplasty on voice recovery

OBJECTIVE

Type-I thryroplasty, also known as medialization thyroplasty (MT) and autologous fat injection laryngoplasty (FIL) are one of the main surgical treatments for unilateral vocal fold paralysis (UVFP). Both procedures have the same concept of completing the glottal closure by medializing the vocal fold, although the surgical approaches are quite different. In order to assess these surgical effects, we examined the treatment outcomes and benefits of the two surgeries.

METHODS

We collected data from the 135 phonosurgeries that we performed out of 375 patients with UVFP at Osaka Voice Center, Osaka Kaisei Hospital from January 2009 to February 2013. After excluding cases with glottal level differences on phonation, either MT or FIL were performed on 80 cases. The inclusion criteria for the present study were: (1) patients had no history of previous phonosurgery, and (2) functional evaluations were available before/after surgery. Consequently, 43 participants (12 for MT and 31 for FIL) were enrolled in this study. Surgical effects were evaluated by means of the maximum phonation time (MPT), pitch period perturbation quotient (PPQ), amplitude perturbation quotient (APQ), and harmonic to noise ratio (HNR) just before, one month, and 6 months after surgery.

RESULTS

Both MT and FIL showed significant improvement in MPT (MT, p = 0.005; FIL, p < 0.001) and PPQ (MT, p = 0.047; FIL, p = 0.041) at 1 month postoperation. We also compared the variation of each variable between the two procedures, but there were no significant differences in these parameters. However, MPT, APQ, and HNR at the post-MT after 6 months worsened compared to those at 1 month posttreatment, whereas MPT showed only a slight decrease from the 1st month to the 6th month in those with FIL.

CONCLUSION

Both MT and FIL were effective for the voice recovery in patients with UVFP. Our findings suggest that surgical results in FIL might be better than those in MT 6 months after surgery, although there were no significant differences between these two procedures 1 month postoperation.

Comparison of arytenoid vertical height discrepancy in normal versus patients with vocal cord palsy

OBJECTIVE

Cadaveric experiments and more recently clinical data have demonstrated that patients with vertical height discrepancy between their arytenoids experience poorer voice outcomes in patients with unilateral vocal cord palsy (UVP) after medialisation laryngoplasty. However, the presence or severity of height discrepancy in normal patients without UVP has not yet been clearly defined.

STUDY DESIGN

Case-control study.

SETTING

Tertiary Australian hospitals.

SUBJECTS AND METHODS

A retrospective review was performed on patients who underwent high computed tomography imaging of the neck. Scans were assessed for discrepancy in arytenoid vertical height discrepancy and compared to a cohort with known UVP.

RESULTS

44 normal patients (50% female, mean age 57.6 ± 14.8 years) were compared to 23 patients with UVP (43.4% female, mean age 52.3 ± 14.9 years.) Normal patients were found to have a smaller height discrepancy compared to UVP patients (student's t-test,2.00 mm ± 0.00 vs 2.39 mm ± 0.72, p < .001.) CONCLUSION: This study suggests that discrepancy is pathologic, and it is plausible that this results in acoustic consequences.

Development of three-dimensional laryngostroboscopy for office-based laryngeal diagnostics and phonosurgical therapy

OBJECTIVE

To develop a three-dimensional (3D) laryngostroboscopic examination unit, compare the optic playback quality in relation to established 2D procedures, and report the first case series using 3D rigid laryngostroboscopy for diagnosis and management of laryngotracheal diseases.

STUDY DESIGN

Laboratory study, prospective case series.

METHODS

The optical efficacy of newly developed rigid 3D endoscopes was examined in a laboratory setting. Diagnostic suitability was investigated in 100 subjects (50 male, 50 female) receiving 2D high-definition (HD) and 3D laryngostroboscopy. Two of the subjects subsequently underwent 3D-assisted office-based transoral phonosurgery under local anesthesia. Main outcome measures were comparative visualization of laryngotracheal pathologies, influence on preoperative planning, and evaluation of prognostic factors for the outcome of phonosurgical interventions.

RESULTS

Three-dimensional endostroboscopic procedures were effectively optimized to establish an examination protocol for all-day clinical use. Office-based 3D laryngostroboscopy was successfully applied in subjects with normal anatomy (n = 10) and various laryngotracheal findings (n = 90). In comparison to 2D HD videolaryngostroboscopy, the 3D view offered enhanced visualization of laryngotracheal anatomy, with qualitatively improved depth perception and spatial representation. In organic pathologies, this resulted in a more precise indication of phonosurgical procedures, increased accuracy in surgical planning, facilitated office-based endoscopic surgery, and better evaluation of prognostic factors for the outcome of phonosurgical interventions.

CONCLUSION

Three-dimensional laryngostroboscopy proved to increase the understanding of functional and surgical anatomy. Its application has enormous potential for improving the diagnostic value of laryngoscopy, surgical precision in laryngotracheal interventions, tissue preservation, and methods of teaching.

LEVEL OF EVIDENCE

NA Laryngoscope, 128:2823-2831, 2018.

The larynx ruler to measure height and profile of vocal folds: a proof of concept

INTRODUCTION

Glottic leakage during phonation is a direct consequence of unilateral vocal fold (VF) paralysis. This air leakage can be in the horizontal plane and in the vertical plane. Presently, there is no easily applicable medical device allowing noninvasive, office-based measurement of the relative vertical position of the VFs. The larynx ruler (LR) is a laser-based measuring device that could meet the previously stated need, using a flexible endoscope. This study represents a proof of concept regarding the use of the LR in assessing VF relative positions in the vertical plane.

MATERIALS AND METHODS

One fresh male human cadaver larynx, free of neurologic and anatomic disease, was explored with the LR system through the operative channel of a flexible gastroenterology video-endoscope. The tip of the video-endoscope was located in the laryngeal vestibule. The right crico-arytenoid joint was posteriorly disarticulated. Tilting of the VF was obtained by pulling or pushing the arytenoid cartilage with a mosquito forceps fixed to the stump of the previously sectioned superior tip of the posterior crico-arytenoid muscle allowing anterior and posterior tilting of the arytenoid cartilage in order to induce an elevation or a depression of the VF process. Ten "push" and ten "pull" sessions were performed. The distance from the tip of the video-endoscope to each illuminated pixel of the laser beam was recorded. The level difference between the left and right VFs was measured for each recording.

RESULTS

Data provided by the LR were consistently in accordance with the movements applied on the VFs. The accuracy of 0.2 mm of the LR is compatible with the envisioned applications for the human larynx.

CONCLUSION

The LR system represents a feasible technique to evaluate respective vertical position of VFs in the human larynx. Technical limitations were identified that will require improvements before experimental use on human beings.