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Shuman EA, Dwyer CD. Training for Awake, Office-Based Laryngeal Procedures-The Laryngology Fellow's Perspective. Laryngoscope 2024; 134:873-881. [PMID: 37665107 DOI: 10.1002/lary.31033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 08/08/2023] [Accepted: 08/22/2023] [Indexed: 09/05/2023]
Abstract
OBJECTIVE The aim was to explore recent laryngology graduates' perspectives on their experience, competency, and challenges learning office-based procedures during fellowship training in the United States and Canada. METHODS Anonymous 22-item questionnaire survey was distributed electronically to fellowship-trained laryngologists having completed fellowship within past 5 years. RESULTS Ninety fellowship-trained laryngologists between 2018 and 2022 were surveyed. Response rate was 48.9% (n = 44), 1 declined participation, with 20 different fellowship programs represented. Fellows were frequently provided the opportunity to act as primary surgeon for most procedures, except for laryngeal botulinum toxin injection, diagnostic laryngeal electromyography, trans-nasal esophagoscopy, secondary tracheoesophageal puncture, and high-resolution pharyngeal manometry. A majority reported high (n = 27, 62.8%) or moderate (n = 12, 27.9%) confidence with vocal fold injection augmentation. Various techniques were taught: transoral (74.4%), cricothyroid (74.4%), thyrohyoid (69.8%), transcartilagenous (14.0%), and catheter-needle (25.6%). Numerous statistically significant associations with independent procedure involvement and competence were identified. Laryngeal botulinum toxin injection was a procedure performed with high frequency but low volume of independent fellow involvement, and the procedure with which fellows reported wanting more practice learning. Most common training barriers included patient being awake, patient consenting to trainee performing the procedure, and the technical challenge/complexity of the procedure. Teaching methods/tools largely focused on informal debriefing (97.3%) and case by case troubleshooting (81.1%). CONCLUSIONS Laryngology fellows are well trained with favorable perceived levels of competence for numerous office-based procedures, particularly vocal fold injection augmentation. Procedures for which fellows reported a low level of independent participation trended towards lower perceived competency. LEVEL OF EVIDENCE 5 Laryngoscope, 134:873-881, 2024.
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Affiliation(s)
- Elizabeth A Shuman
- Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Christopher D Dwyer
- Brigham & Women's Hospital, Department of Surgery, Division of Otolaryngology, Harvard University, Boston, Massachusetts, U.S.A
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Gao WZ, Paoletti MF, Bensoussan Y, Bhatt NK, Shuman EA, Grant N, O'Dell K, Johns MM. Prospective >12 Months Outcomes After Vocal Fold Injection Medialization With Silk Microparticle-Hyaluronic Acid Material. Laryngoscope 2023. [PMID: 37676072 DOI: 10.1002/lary.31039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 07/11/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE Vocal fold injection medialization (VFIM) is widely used as an initial treatment for unilateral vocal fold paralysis (UVFP). Current practices employ materials that share the limitation of temporary clinical effect from variable resorption rates. A novel silk protein microparticle-hyaluronic acid-based material (silk-HA) has demonstrated cellular infiltration and tissue deposition that may portend a durable medialization effect. We report on ≥12 months outcomes after VFIM with silk-HA. METHODS Prospective open-label study of patients with UVFP that elected treatment with VFIM with silk-HA. Blinded experts rated laryngeal stroboscopic exams. RESULTS Seventeen patients with UVFP underwent VFIM with silk-HA. Twelve of the 17 patients have ≥12 months follow-up. Seven patients demonstrated durable treatment benefit ≥12 months after injection with median improvement of 19 (p = 0.0156) in VHI-10. There was no significant change in VHI-10 between 1 and 12 months for these patients. Blinded ratings indicated that 5/7 patients with sustained improvements in VHI-10 exhibited complete or touch glottal closure at 12 months. Two of the seven patients exhibited a small (<1 mm) glottal gap at 12 months. Seven patients experienced initial benefit with later regression 3-4 months after injection. CONCLUSION VFIM with silk-HA can offer durable improvement in voice-related outcomes for UVFP past 12 months. A subset of patients treated with silk-HA experienced early loss of effect around 3-4 months postinjection. Clinical factors predictive of sustained treatment response to silk-HA injection require further exploration. LEVEL OF EVIDENCE 3 Laryngoscope, 2023.
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Affiliation(s)
- William Z Gao
- UChicago Voice Center, Department of Surgery, Section of Otolaryngology-Head & Neck Surgery, University of Chicago, Chicago, Illinois, U.S.A
| | - Marcus F Paoletti
- Keck School of Medicine of University of Southern California, Los Angeles, California, U.S.A
| | - Yael Bensoussan
- USF Health Voice Center, Department of Otolaryngology-Head & Neck Surgery, University of Southern Florida, Tampa, Florida, U.S.A
| | - Neel K Bhatt
- Division of Laryngology, Department of Otolaryngology-Head & Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - Elizabeth A Shuman
- USC Voice Center, Department of Otolaryngology-Head & Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Nazaneen Grant
- Department of Otolaryngology-Head & Neck Surgery, Georgetown University Medical Center, Washington, DC, U.S.A
| | - Karla O'Dell
- USC Voice Center, Department of Otolaryngology-Head & Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
| | - Michael M Johns
- USC Voice Center, Department of Otolaryngology-Head & Neck Surgery, University of Southern California, Los Angeles, California, U.S.A
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Muacevic A, Adler JR. Use of Botulinum Toxin in Spasmodic Dysphonia: A Review of Recent Studies. Cureus 2023; 15:e33486. [PMID: 36628391 PMCID: PMC9825114 DOI: 10.7759/cureus.33486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 01/09/2023] Open
Abstract
Spasmodic dysphonia (SD), also known as laryngeal dystonia, is a neurological voice disorder that causes involuntary spasms of the vocal cord muscles. This impacts speech to varying degrees and results in strained and strangled voice quality, as in adductor spasmodic dysphonia, or weak, quiet, and breathy, as in abductor spasmodic dysphonia. While there is currently no cure for SD, voice therapy and chemodenervation with botulinum toxin (btx) injections remain the mainstay of management. Surgery may be performed in some cases; however, btx injections are widely used to treat both adductor and abductor forms of SD. While btx injections may show vocal improvement in both types of SD, results can depend on several factors such as the general health of the patient, onset and severity of the condition, dosage, interval between injections, and expertise of the practitioner. While many studies have documented the efficacy of btx for improving vocal symptoms in individuals with SD, this review aims to discuss some of those studies from the last 10 years.
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Ng WC, Lokanathan Y, Baki MM, Fauzi MB, Zainuddin AA, Azman M. Tissue Engineering as a Promising Treatment for Glottic Insufficiency: A Review on Biomolecules and Cell-Laden Hydrogel. Biomedicines 2022; 10:biomedicines10123082. [PMID: 36551838 PMCID: PMC9775346 DOI: 10.3390/biomedicines10123082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/11/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022] Open
Abstract
Glottic insufficiency is widespread in the elderly population and occurs as a result of secondary damage or systemic disease. Tissue engineering is a viable treatment for glottic insufficiency since it aims to restore damaged nerve tissue and revitalize aging muscle. After injection into the biological system, injectable biomaterial delivers cost- and time-effectiveness while acting as a protective shield for cells and biomolecules. This article focuses on injectable biomaterials that transport cells and biomolecules in regenerated tissue, particularly adipose, muscle, and nerve tissue. We propose Wharton's Jelly mesenchymal stem cells (WJMSCs), induced pluripotent stem cells (IP-SCs), basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), hepatocyte growth factor (HGF), insulin growth factor-1 (IGF-1) and extracellular vesicle (EV) as potential cells and macromolecules to be included into biomaterials, with some particular testing to support them as a promising translational medicine for vocal fold regeneration.
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Affiliation(s)
- Wan-Chiew Ng
- Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Yogeswaran Lokanathan
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Marina Mat Baki
- Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Mh Busra Fauzi
- Centre for Tissue Engineering and Regenerative Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Ani Amelia Zainuddin
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Mawaddah Azman
- Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
- Correspondence:
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Park SJ, Park YH, Jeong WJ, Cha W. Prolonged persistence of hyaluronic acid after suboptimal vocal fold injection. Ear Nose Throat J 2022:1455613221082619. [PMID: 35324320 DOI: 10.1177/01455613221082619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hyaluronic acid (HA) is a commonly used injectable material in temporary vocal fold injections (VFI) in patients with unilateral vocal fold paralysis (UVFP). Hyaluronic acid has generally been known for its three-six months of longevity following VFI. Owing to recent advances in cross-linking technologies, the longevity of HA-based materials, including deep-volumizing cross-linked HA used in VFI, has been improved. However, persisting injectable material in the subepithelial space poses undesirable complications following VFI. Herein, we report 2 cases of unexpected persistence of superficially injected cross-linked HA. In the first case, a 70-year-old man with iatrogenic UVFP received VFI with cross-linked HA three years ago and was referred for persistent dysphonia. Previously injected HA spilled out from the vocal fold (VF) when an epithelial incision was made in the subepithelial cystic lesion. In the second case, a 72-year-old woman with iatrogenic UVFP received VFI with cross-linked HA that migrated into the subepithelial space. Diffuse swelling of the injected VF caused dysphonia that lasted for a year. The previously injected HA spilled out when an epithelial incision was made in the swollen VF. Since superficially injected deep-volumizing cross-linked HA can persist for up to three years, laryngologists should be aware of possible sequelae upon suboptimal VFI with cross-linked HA.
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Affiliation(s)
- Sung Joon Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University Hospital, 37985Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Young Hak Park
- Department of Otorhinolaryngology-Head and Neck Surgery, 58976Yeouido St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Woo-Jin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, 65462Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Republic of Korea
| | - Wonjae Cha
- Department of Otorhinolaryngology-Head and Neck Surgery, 65462Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Republic of Korea
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González-Herranz R, Navarro-Mediano A, Hernández-García E, Plaza G. Autologous Adipose Tissue Injection of Vocal Cords in Presbyphonia. Otolaryngol Head Neck Surg 2021; 167:118-124. [PMID: 34546813 DOI: 10.1177/01945998211045292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This series evaluates the long-term results of autologous adipose injection (AAI) in patients older than 65 years with presbyphonia. STUDY DESIGN Retrospective cohort study. SETTING Academic secondary medical center. METHODS This was a retrospective study with a minimum follow-up of 12 months. All patients underwent AAI for atrophy of both vocal folds due to presbyphonia. We measured subjective parameters as Voice Handicap Index-10 (VHI-10) or GRBAS scale (grade, roughness, breathiness, asthenia, strain) and objective measures such as maximum phonation time (MPT) or square pixel closure defect. We reviewed the medical records of patients undergoing AAI during the 2011-2018 period. An analysis of the demographic variables of the group was performed, as well as the values of VHI-10, GRBAS, and MPT, and the minimum closure defect measured in square pixels and the number of closed frames in the glottal cycle before and after the intervention. RESULTS At 12 months, 17 of 18 patients reported subjective and VHI-10 improvement. The mean preoperative VHI-10 (26.7) was significantly higher than the postoperative value (14.4), and the GRBAS scale had a preoperative mean of 8.7 and a postoperative mean of 4.3, both with statistical significance. MPT increased from 7.7 to 12.4 seconds (P < .0001). The minimum closure defect measurements obtained in square pixels changed from 305 to 124, achieving complete closure in 3 patients. The closed phase of the glottal cycle change from 14.3% to 38.2% after the AAI. CONCLUSIONS AAI improves long-term vocal fold closure, demonstrating utility in patients with presbyphonia.
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Affiliation(s)
- Ramón González-Herranz
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada, Madrid, Spain.,Department of Otolaryngology, Hospital Universitario La Zarzuela, Madrid, Spain
| | | | - Estefanía Hernández-García
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada, Madrid, Spain.,Department of Otolaryngology, Hospital Universitario La Zarzuela, Madrid, Spain
| | - Guillermo Plaza
- Department of Otolaryngology, Hospital Universitario de Fuenlabrada, Madrid, Spain.,Department of Otolaryngology, Hospital Universitario La Zarzuela, Madrid, Spain
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Miles ER, Krishna PD, Inman JC, Lee SC, Walker PC, Simental AA, Crawley BK. Dysphagia Severity and Outcomes Following Iatrogenic High Vagal Nerve Injury. Ann Otol Rhinol Laryngol 2021; 131:493-498. [PMID: 34157900 DOI: 10.1177/00034894211026991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine severity of dysphagia and outcomes following iatrogenic high vagal nerve injury. METHODS Retrospective chart review of all patients with iatrogenic high vagal nerve injury that were seen at a tertiary referral center from 2012 to 2020. RESULTS Of 1304 patients who met criteria for initial screening, 18 met all inclusion criteria. All 18 required intervention to address postoperative dysphagia. Eleven required enteral feeding tubes with 7 eventually able to advance to exclusively per oral diets. Fourteen underwent vocal fold injection and 6 underwent laryngeal framework surgery. Sixteen pursued swallowing therapy with speech language pathology. Patients lost a mean of 8.6 kg of weight in the 6 months following the injury. Swallowing function on the Functional Outcome Swallowing Scale (FOSS) and Functional Oral Intake Scale (FOIS) was 4.4 and 2.4 respectively immediately following the injury and improved to 1.9 and 5.3 at the last follow-up. No patients had complete return of normal swallowing function at last follow up. CONCLUSION Iatrogenic high vagal injury causes significant lasting dysphagia which improves with intervention but does not completely resolve. Interventions such as vocal fold injection, medialization laryngoplasty, cricopharyngeal myotomy, or swallowing therapy may be required to reestablish safe swallowing in these patients.
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Affiliation(s)
- Ethan R Miles
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Priya D Krishna
- Loma Linda Voice and Swallowing Center, Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health System, Loma Linda, CA, USA
| | - Jared C Inman
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health System, Loma Linda, CA, USA
| | - Steve C Lee
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health System, Loma Linda, CA, USA
| | - Paul C Walker
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health System, Loma Linda, CA, USA
| | - Alfred A Simental
- Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health System, Loma Linda, CA, USA
| | - Brianna K Crawley
- Loma Linda Voice and Swallowing Center, Department of Otolaryngology-Head and Neck Surgery, Loma Linda University Health System, Loma Linda, CA, USA
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8
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Belsky MA, Lin RJ, Rosen CA, Munin MC, Smith LJ. Vocal fold injection material does not preclude interpretation of laryngeal electromyography. Muscle Nerve 2021; 64:104-108. [PMID: 33961288 DOI: 10.1002/mus.27262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 04/26/2021] [Accepted: 05/04/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Temporary vocal fold injection (VFI) is a common treatment for acute and subacute vocal fold paralysis (VFP). Laryngeal electromyography (LEMG) is useful for diagnosing neurogenic causes of VFP. This study evaluated whether the presence of VFI material prevents interpretation of LEMG in patients with acute and subacute VFP. METHODS Patients with acute and subacute unilateral VFP (onset ≤6 mo) who underwent temporary VFI within 3 mo preceding LEMG were evaluated. A matched control group that did not undergo VFI was also studied. The LEMG team (laryngologist and electromyographer) performed and interpreted LEMG using a pre-specified protocol, including qualitative and quantitative motor unit analysis. RESULTS Eighteen patients with VFI underwent LEMG successfully with interpretation of spontaneous activity and motor unit recruitment. Fourteen patients were seen in follow-up to determine accuracy of established LEMG prognosis. Seven of seven subjects with poor LEMG prognosis did not recover vocal fold motion. Five of seven subjects with fair LEMG prognosis recovered vocal fold motion. Findings were similar for the control group. DISCUSSION VFI augmentation material did not prevent interpretation of meaningful LEMG data in patients with acute and subacute VFP, and accurate prognoses of vocal fold motion recovery were established.
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Affiliation(s)
- Michael A Belsky
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - R Jun Lin
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Clark A Rosen
- UCSF Voice and Swallowing Center, Division of Laryngology, Department of Otolaryngology - Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Libby J Smith
- Department of Otolaryngology, University of Pittsburgh Voice Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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9
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Bergeron M, Giliberto JP, Tabangin ME, de Alarcon A. Vocal Fold Injection Augmentation for Post-Airway Reconstruction Dysphonia: A Case Series. Ann Otol Rhinol Laryngol 2021:34894211012594. [PMID: 33949216 DOI: 10.1177/00034894211012594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Post airway reconstruction dysphonia (PARD) is common and has a significant effect on the quality of life of patients. Vocal fold injection augmentation (VFIA) is one treatment that can be used to improve glottic insufficiency in some patients. The goal of this study was to characterize the use and outcomes of VFIA for PARD. METHODS Retrospective chart review from January 2007 to July 2018 at a tertiary pediatric care center. Consecutive patients with PARD who underwent VFIA, who had a preoperative voice evaluation and a follow-up evaluation within 3 months after VFIA (fat, carboxymethylcellulose gel, hyaluronic acid). RESULTS Thirty-four patients (20 female) underwent VFIA. The mean age at the time of the injection was 13.6 years (SD 6.1). Twenty patients (58.8%) had a history of prematurity and a mean of 1.8 open airway surgeries. After injection, 29/34 patients (85.3%) noted a subjective voice improvement. The baseline Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) overall severity score decreased by a mean of 5.7 (SD = 19.6) points, P = .12. Total pediatric Voice Handicap Index (pVHI) improved by 6.0 (SD = 19.5) points, from 57.4 (SD = 20.0) to 51.4 (SD = 17.2), P = .09. Functional pVHI subscore demonstrated a significant improvement, with a decrease of 3.4 (SD = 7.3) points, P = .02. All procedures were performed as an overnight observation and no complication occurred. CONCLUSION Patients with PARD represent a complex subset of patients. VFIA is a straightforward intervention that may improve voice perception. Many patients reported subjective improvement despite minimal objective measurement. Further work is warranted to elucidate the role of injection in management of PARD.
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Affiliation(s)
- Mathieu Bergeron
- Department of Pediatric Otolaryngology, CHU Sainte-Justine, Montreal, QC, Canada
| | - John Paul Giliberto
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Meredith E Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alessandro de Alarcon
- Division of Pediatric Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati, Cincinnati, OH, USA
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Smith SL, Titze IR, Storck C, Mau T. Effect of Vocal Fold Implant Placement on Depth of Vibration and Vocal Output. Laryngoscope 2019; 130:2192-2198. [PMID: 31643091 DOI: 10.1002/lary.28365] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 07/26/2019] [Accepted: 09/25/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Most type 1 thyroplasty implants and some common injectable materials are mechanically stiff. Placing them close to the supple vocal fold mucosa can potentially dampen vibration and adversely impact phonation, yet this effect has not been systematically investigated. This study aims to examine the effect of implant depth on vocal fold vibration and vocal output. STUDY DESIGN Computational simulation. METHODS Voice production was simulated with a fiber-gel finite element computational model that incorporates a three-layer vocal fold composition (superficial lamina propria, vocal ligament, thyroarytenoid muscle). Implants of various depths were simulated, with a "deeper" or more medial implant positioned closer to the vocal fold mucosa and replacing more muscle elements. Trajectories of surface and within-tissue nodal points during vibration were produced. Outcome measures were the trajectory radii, fundamental frequency (F0 ), sound pressure level (SPL), and smoothed cepstral peak prominence (CPPS) as a function of implant depth. RESULTS Amplitude of vibration at the vocal fold medial surface was reduced by an implant depth of as little as 14% of the total transverse vocal fold depth. Increase in F0 and decrease in CPPS were noted beyond 30% to 40% implant depth, and SPL decreased beyond 40% to 60% implant depth. CONCLUSIONS Commonly used implants can dampen vibration "from a distance," ie, even without being immediately adjacent to vocal fold mucosa. Since implants are typically placed at depths examined in this study, stiff implants likely have a negative vocal impact in a subset of patients. Softer materials may be preferable, especially in bilateral medialization procedures. LEVEL OF EVIDENCE N/A Laryngoscope, 130:2192-2198, 2020.
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Affiliation(s)
- Simeon L Smith
- National Center for Voice and Speech, University of Utah, Salt Lake City, Utah, U.S.A
| | - Ingo R Titze
- National Center for Voice and Speech, University of Utah, Salt Lake City, Utah, U.S.A.,Department of Communication Sciences and Disorders, University of Iowa, Iowa City, Iowa, U.S.A
| | - Claudio Storck
- Department of Otorhinolaryngology-Head and Neck Surgery, Division of Phoniatrics, University Hospital Basel, Basel, Switzerland
| | - Ted Mau
- Clinical Center for Voice Care, Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
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11
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Moore JE, Rathouz PJ, Havlena JA, Zhao Q, Dailey SH, Smith MA, Greenberg CC, Welham NV. Practice variations in voice treatment selection following vocal fold mucosal resection. Laryngoscope 2016; 126:2505-2512. [PMID: 26972900 PMCID: PMC5018919 DOI: 10.1002/lary.25911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 12/17/2015] [Accepted: 01/14/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVES/HYPOTHESIS To characterize initial voice treatment selection following vocal fold mucosal resection in a Medicare population. STUDY DESIGN Retrospective analysis of a large, nationally representative Medicare claims database. METHODS Patients with > 12 months of continuous Medicare coverage who underwent a leukoplakia- or cancer-related vocal fold mucosal resection (index) procedure during calendar years 2004 to 2009 were studied. The primary outcome of interest was receipt of initial voice treatment (thyroplasty, vocal fold injection, or speech therapy) following the index procedure. We evaluated the cumulative incidence of each postindex treatment type, treating the other treatment types as competing risks, and further evaluated postindex treatment utilization using the proportional hazards model for the subdistribution of a competing risk. Patient age, sex, and Medicaid eligibility were used as predictors. RESULTS A total of 2,041 patients underwent 2,427 index procedures during the study period. In 14% of cases, an initial voice treatment event was identified. Women were significantly less likely to receive surgical or behavioral treatment compared to men. From age 65 to 75 years, the likelihood of undergoing surgical treatment increased significantly with each 5-year age increase; after age 75 years, the likelihood of undergoing either surgical or behavioral treatment decreased significantly every 5 years. Patients with low socioeconomic status were significantly less likely to undergo speech therapy. CONCLUSION The majority of Medicare patients do not undergo voice treatment following vocal fold mucosal resection. Further, the treatments analyzed here appear disproportionally utilized based on patient sex, age, and socioeconomic status. Additional research is needed to determine whether these observations reflect clinically explainable differences or disparities in care. LEVEL OF EVIDENCE 2c. Laryngoscope, 126:2505-2512, 2016.
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Affiliation(s)
- Jaime E Moore
- Division of Otolaryngology, Department of Surgery , University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Paul J Rathouz
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Jeffrey A Havlena
- Division of General Surgery, Department of Surgery , University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Qianqian Zhao
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Seth H Dailey
- Division of Otolaryngology, Department of Surgery , University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Maureen A Smith
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Caprice C Greenberg
- Division of General Surgery, Department of Surgery , University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A
| | - Nathan V Welham
- Division of Otolaryngology, Department of Surgery , University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A..
- Wisconsin Surgical Outcomes Research Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A..
- Health Innovation Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, U.S.A..
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Young WG, Hoffman MR, Koszewski IJ, Whited CW, Ruel BN, Dailey SH. Voice Outcomes following a Single Office-Based Steroid Injection for Vocal Fold Scar. Otolaryngol Head Neck Surg 2016; 155:820-828. [PMID: 27507145 DOI: 10.1177/0194599816654899] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 05/25/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Persistent dysphonia from vocal fold scar remains a clinical challenge, with current therapies providing inconsistent outcomes. We evaluated voice outcomes after a single office-based steroid injection. STUDY DESIGN Case series with chart review. SETTING Academic medical center. SUBJECTS AND METHODS This study was based on pre- and postoperative analysis of patient-reported, perceptual, acoustic, aerodynamic, and videostroboscopic parameters. The sample comprised 25 patients undergoing office-based dexamethasone injection into the superficial lamina propria for mild/moderate vocal fold scar. Average follow-up was 13.7 ± 4.4 weeks; patients completed 3.5 ± 2.3 sessions of voice therapy between assessments. Complete data sets were not available for each parameter; sample size is noted with results. RESULTS Voice handicap index (n = 24; P < .001) and glottal function index (n = 22; P < .001) decreased after injection. Total GRBAS score (grade, roughness, breathiness, asthenia, strain) decreased (n = 25; P < .001). Fundamental frequency range increased (n = 24; P = .024). Phonation threshold pressure decreased (n = 14; P = .017). Videostroboscopic parameters of vocal fold edge (P = .004), glottic closure (P = .003), and right mucosal wave (P = .016) improved after injection. CONCLUSIONS Office-based steroid injection combined with voice therapy for mild/moderate vocal fold scar is associated with improved patient-reported and functional voice measures. These findings provide preliminary support for this approach. Importantly, the procedure is low risk and can be performed in the office, thus offering a simple treatment alternative to patients with a disorder that has traditionally been difficult to manage. Prospective studies evaluating the effects of multiple injections are warranted.
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Affiliation(s)
- William G Young
- Proliance Eastside Ear Nose and Throat, Kirkland, Washington, USA.,Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Matthew R Hoffman
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Ian J Koszewski
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Chad W Whited
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA.,Austin Ear, Nose & Throat Clinic, Austin, Texas, USA
| | - Brienne N Ruel
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Seth H Dailey
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
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Mahboubi H, Mohraz A, Verma SP. Evaluation of Heating and Shearing on the Viscoelastic Properties of Calcium Hydroxyapatite Used in Injection Laryngoplasty. Otolaryngol Head Neck Surg 2016; 154:498-501. [PMID: 26814211 DOI: 10.1177/0194599815625206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 12/11/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare the viscoelastic properties of calcium hydroxyapatite (CaHA) to carboxymethylcellulose (CMC) injectables used for injection laryngoplasty and determine if they are affected by heating and shearing. STUDY DESIGN Experimental. SETTING University laboratory. SUBJECTS AND METHODS Vocal fold injection laryngoplasty with CaHA is oftentimes challenging due to the amount of pressure necessary to push the injectate through a needle. Anecdotal techniques, such as heating the product, have been suggested to facilitate injection. The viscoelastic properties of CaHA and CMC were measured with a rheometer. The effects of heating and shearing on sample viscoelasticity were recorded. RESULTS CaHA was 9.5 times more viscous than CMC (43,100 vs 4540 Pa·s). Heating temporarily decreased the viscosity of CaHA by 32%. However, it also caused the viscosity to subsequently increase after time. Shearing of CaHA reduced its viscosity by 26%. Heating and shearing together temporarily reduced the viscosity of CaHA by 52%. CONCLUSION A combination of heating and shearing had a more profound effect than heating or shearing alone on the viscosity of CaHA, potentially making it easier to inject temporarily. Long-term and in vivo studies are required to further analyze the effect of heating and shearing on CaHA injectables.
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Affiliation(s)
- Hossein Mahboubi
- University Voice and Swallowing Center, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine School of Medicine, Irvine, California, USA
| | - Ali Mohraz
- Department of Chemical Engineering and Materials Science, University of California Irvine, Irvine, California, USA
| | - Sunil P Verma
- University Voice and Swallowing Center, Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine School of Medicine, Irvine, California, USA
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