Vocal fold augmentation with injectable calcium hydroxylapatite: short-term results.

Symptoms of unilateral vocal fold paralysis are improved significantly by augmenting the paralyzed vocal fold via vocal fold injection. In this trial, augmentation with a new calcium hydroxylapatite implant was evaluated. In addition, two different phonosurgical injection techniques were used, and these procedures were compared for accuracy and reliability. A total of 11 terminal patients with unilateral vocal fold paralysis underwent vocal fold injection with calcium hydroxylapatite. Efficacy of the implant was evaluated by comparing results from the Voice Handicap Index (VHI) and mean airflow measurements before and 6 months after injection. Surgeon evaluations determined the comparative benefits of either endoscopic direct vocal fold injection or percutaneous vocal fold injection. Six-month data were obtained for a cohort of five patients. VHI scores improved for all five patients available for full evaluation and four of the five achieved improvements in mean airflow rates. Of the remaining patients, one later had a medialization laryngoplasty, two died from their terminal diseases before the 6-month follow-up, and two of the remaining three reported satisfaction with the results via telephone follow-up. Vocal fold injection via endoscopic, direct laryngoscopy was found to be a more reliable procedure for vocal fold injection than percutaneous injection. Slight overinjection (10% to 15%) was found to provide optimum results. Vocal fold injection of calcium hydroxylapatite for unilateral vocal fold paralysis improved voice quality and reduced mean airflow rates in this patient group with short-term results. Long-term studies are needed to confirm the durability of these findings.     

Voice-Related Quality of Life (V-RQOL) following type I thyroplasty for unilateral vocal fold paralysis

Unilateral vocal fold paralysis is a common clinical problem which frequently causes severe dysphonia. Various treatment options exist for this condition, with the type I thyroplasty being one of the more commonly performed surgical procedures for vocal rehabilitation. The Voice-Related Quality of Life (V-RQOL) Measure is a validated outcomes instrument for voice disorders. This study measured the V-RQOL of patients with unilateral vocal fold paralysis who had undergone a type I thyroplasty and compared these scores to those of patients with untreated and uncompensated unilateral vocal fold paralysis and to normals. Treated patients had significantly higher domain and overall V-RQOL scores than untreated patients, but also scored lower than normals. These differences were true across gender and age. Patients who were more distant from surgery had lower V-RQOL scores than those who had more recently been treated. It is concluded that type I thyroplasty leads to a significantly higher V-RQOL for patients with unilateral vocal fold paralysis. This study also demonstrates further the utility of patient-oriented measures of treatment outcome.     

Vocal Fold Paralysis Following Radiotherapy for Nasopharyngeal Carcinoma: Laryngeal Electromyography Findings

Laryngeal electromyography was used to study the pattern of neurological injury in three patients with unilateral vocal fold paralysis following radiotherapy for nasopharyngeal carcinoma. The thyroarytenoid and cricothyroid muscles were assessed to give an indication of recurrent and superior laryngeal nerve function. Two patients demonstrated both recurrent and superior laryngeal neuropathy suggesting injury at the skull base. The other patient had only recurrent laryngeal neuropathy indicating more distal involvement. Subclinical neuropathic changes were seen in two cases on the side contralateral to the vocal fold paralysis. These patients may be at increased risk of developing bilateral vocal fold paralysis and potentially life-threatening airway obstruction. Long-term follow-up is recommended for such patients, especially if medialization thyroplasty is being considered. This is the first report describing the use of electromyography to determine the pattern of nerve injury in patients with vocal fold paralysis following head and neck radiotherapy.     

Complications of collagen injection of the vocal fold: report of several unusual cases and review of the literature

Injection laryngoplasty is one of the most frequently performed procedures in patients with voice complaints. Various biomaterials have been used to medialize vocal folds or to treat symptoms of vocal fold scar. The ideal biomaterial would be easily injected through a fine-gauge needle, well tolerated, and long lasting. Injectable collagen preparations fulfill at least two of these criteria, and collagen has been used widely for vocal fold injections. MATERIALS AND METHODS: We present a retrospective review of two unusual complications of collagen injection and a review of the relevant literature on the complications of medical use of collagen compounds. RESULTS: Two patients in whom collagen was injected formed firm submucosal deposits that interrupted the normal mucosal wave and produced significant dysphonia. Surgical removal of these deposits restored the mucosal wave and improved voice quality. Management of this unusual complication of human collagen injection in the vocal fold has not been reported previously. Other complications of collagen injection include hypersensitivity reactions to bovine collagen, local abscess formation at injection sites, and possibly induction of collagen vascular disease in some patients. CONCLUSIONS: Although collagen injections of the vocal fold rarely result in complications, physicians using collagen must be familiar with the types of complications that can occur. Proper diagnosis and prompt management of complications can result in good outcomes.     

Preliminary Results of a New Temporary Vocal Fold Injection Material

Temporary vocal fold injection is a valuable procedure for vocal fold paralysis or paresis of uncertain permanency and as a trial augmentation to decide the value of vocal fold augmentation. A new material made from glycerin, carboxymethylcellulose, and water has recently been developed for temporary vocal fold augmentation. Eleven patients underwent vocal fold injection for the treatment of glottal incompetence with this material. The duration of effectiveness of this injection material was 2 to 3 months depending on the injection amount. This new material satisfies several requirements for an ideal temporary vocal fold injection material in terms of injectability, convenience, duration of effectiveness, and safety. The authors conclude that this new material is a good option for temporary vocal fold augmentation.     

The biomechanics of the medialization laryngoplasty(thyroplasty type 1) in an ex vivo canine model

The biomechanics of medialization laryngoplasty are not well understood. An excised canine larynx model was used to test the effects of various sized silicon implants. The vocal fold length, position, and tension were measured. Medialization laryngoplasty did not affect vocal fold length. At the mid-membranous vocal fold, larger shims resulted in greater medialization and tension. Medialization laryngoplasty neither medialized nor stiffened the vocal process to resist lateralizing forces. We conclude that medialization laryngoplasty provides bulk and support for defects of the membranous region of the vocal fold, but does not appear to close a posterior glottal gap. The selection of a surgical procedure to treat glottal incompetence should take into account the unique biomechanical properties of the anterior (membranous vocal folds) and posterior (cartilaginous portion) glottis.     

Sarcoidosis Presenting as Bilateral Vocal Fold Paralysis

Sarcoidosis with cranial polyneuritis and mediastinal granulomatous compression as a cause of unilateral left vocal fold paralysis has been reported infrequently. No case of sarcoidosis causing bilateral vocal fold paralysis in the abducted position has been reported in the Otolaryngology/Voice literature. Vocal fold function can be impacted in sarcoidosis by direct laryngeal involvement or by neural pathways. In the patient described in this case, sarcoid cranial polyneuritis coupled with bilateral paratracheal and mediastinal adenopathy resulted in bilateral vocal fold paralysis. This patient had a dramatic response to treatment with steroids. Sarcoidosis should be included in the differential diagnosis of unilateral or bilateral vocal fold paralysis.     

Voice and Laryngeal Configuration of Men With Unilateral Vocal Fold Paralysis Before and After Medialization

Aim

To describe the laryngeal configuration and the voice of male patients diagnosed with unilateral vocal fold paralysis (UVFP) before and after medialization.

Methods

A retrospective study involving the collection of data from medical records of 142 patients diagnosed with UVFP from January 2003 to April 2009, submitted to auditory-perceptual assessment of voices and visual perception of laryngeal images before and after medialization.

Results

The study included data from 24 male patients, with an average of 60.7 years, who underwent three surgical medialization techniques (injection of hyaluronic acid, type I thyroplasty, and injection of Teflon). Before treatment, the position of the paralyzed vocal fold was seen to have a significant influence to the passing of the healthy vocal fold beyond the midline and on the overall degree of dysphonia. After treatment, the complete glottic closure; the free margin of the linear vocal fold; paralyzed vocal fold in the median position, reduction of hoarseness, roughness and breathiness (more frequently mild), and asthenia (more frequently normal and mild); tension and instability (more frequency normal); and a decrease in the overall degree of dysphonia were found to be significant.

Conclusion

The position of the paralyzed vocal fold influences the position of the healthy vocal fold in relation to the midline and the overall degree of dysphonia. All three treatments improved the glottic configuration and the voice of patients with UVFP.     

Allograft (Alloderm) and Autograft (Temporalis Fascia) Implantation for Glottic Insufficiency: A Novel Approach

Objective

Traditionally, glottic insufficiency because of scar, atrophy, and sulcus has been treated by injection or medialization laryngoplasty. These procedures do not reestablish the vertical height of the vocal fold margin. We propose soft tissue augmentation laryngoplasty with allograft (sheet Alloderm; LifeCell Corporation, Branchburg, NJ) or autograft (temporalis fascia) via a minithyrotomy or a transoral approach.

Study Design

A retrospective case series analysis of 21 patients treated by sheet Alloderm or temporalis fascia for correction of glottic insufficiency.

Methods

Twenty-one patients with glottic insufficiency secondary to scar, atrophy, or sulcus were treated. Ten failed prior techniques. Seventeen had minithyrotomy by a small fenestration in the thyroid cartilage. Exploration of scar or lamina propria through the fenestration allowed for the creation of a pocket for Alloderm implantation within the intermediate layer of the lamina propria. Four patients underwent a transoral approach by cordotomy with either Alloderm or temporalis fascia implantation, which also allowed for exploration of scar but required repair using sutures. These implantation approaches allowed for both restoration of the layered structure and augmentation of the middle third of the musculomembranous vocal fold. Preoperative and postoperative videostroboscopic examinations were reviewed with review of clinical outcome.

Results

With a median follow-up time of 12 months, patients demonstrated excellent long-term vocal fold augmentation and minimal absorption of the implant in 19 out of 21 patients. There is improved pliability of the vocal fold with good oscillation in scar patients.

Conclusion

Minithyrotomy with soft tissue augmentation is a novel approach for soft tissue augmentation of glottic insufficiency. It has the advantage of augmentation of the medial edge of the vocal fold with a soft tissue implant that has long-term viability. Its role should be explored further in patients with atrophy and scar.     

Analysis of Voice and Quantitative Measurement of Glottal Gap After Thyroplasty Type I in the Treatment of Unilateral Vocal Paralysis

Thyroplasty type I is one of several surgical treatments in which improving the voice of unilateral vocal fold paralysis is the ultimate objective. The goal of the surgery is the medialization of the paralyzed vocal fold. The purpose of this study is to evaluate the effectiveness of thyroplasty type I through acoustical analysis, aerodynamic measures, and quantitative videostroboscopic measurements. We report on 20 patients with unilateral vocal cord paralysis who underwent thyroplasty type I. We performed preoperative and postoperative video image analysis (normalized glottal gap area) and computer-assisted voice analysis (fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, mean phonation time, mean flow rate, mean subglottic pressure) in all patients. The glottal gap was significantly reduced after thyroplasty type I. Postoperative voice quality was characterized by an improved pitch and amplitude pertubation (jitter and shimmer), phonation time (mean phonation time), and subglottic pressure (mean subglottic pressure). Thyroplasty type I is an effective method for regaining glottal closure and vocal function.     

Bilateral vocal fold paralysis: an unsual treatment with botulinum toxin

We presented a patient with bilateral vocal fold paralysis treated with intralaryngeal Botox injection to improve the glottal airway. The use of Botox in this manner has not been previously reported and highlights the value and role of intralaryngeal Botox in changing the configuration of the glottis. The concept and various approaches for using Botox to alter pathologic vocal fold position is reviewed and discussed.     

Vocal fold microsurgery in singers

Some singers with benign vocal fold mucosal lesions remain unacceptably impaired vocally in spite of compliance with a regimen of medical treatment and voice therapy lasting several months—or even years. I present here my experience with 62 singers who, because of this predicament, chose to undergo vocal fold microsurgery. This series is the second largest reported to date in English literature. Procedures are presented which were used for patient selection, education, and vocal retraining, as well as for surgery itself and postoperative care. Results reported here include (a) comparison of my auditory-perceptual ratings of singing voice impairment before and after surgery, (b) preoperative versus postoperative videostroboscopic findings, (c) postoperative rate of return to public singing, and (d) postoperative patient questionnaires which sought to uncover patient/singer perceptions of the results of vocal fold surgery. Excellent results were achieved overall with a very low incidence of untoward results, and no complications were encountered.     

Traumatic vocal fold avulsion injury in a newborn

A full-term newborn developed respiratory compromise in the immediate postparturition period requiring urgent intubation. Evaluation of post-extubation stridor later the same day revealed an avulsion injury extending from the left vocal fold into the lateral glottic musculature. Primary repair was accomplished with anatomic realignment of the torn vocal fold and muscle. Endotracheal intubation was utilized for stenting and the patient was extubated following 3 days of paralysis with sedation. Follow-up examination revealed a reparative granuloma, which was lasered. Eight-week follow-up examination revealed normal vocal fold architecture. At 18 months the patient continues to have a normal voice and normal laryngeal development.     

The evaluation of unilateral vocal fold immobility:Is chest x-ray enough?

Unilateral vocal fold immobility (UVFI) is a sign of underlying disease. No consensus exists regarding the appropriate evaluation. This study was performed to determine the ability of a chest radiograph (CXR) to limit further costly testing. The charts of 169 patients with previously undiagnosed UVFI were reviewed. In 113 patients the etiology was identified during the history and physical examination (H&P), or the H&P led to a directed evaluation. There were nine patients in whom the evaluation was incomplete. There were 47 patients in whom the etiology was not identified during the H%P. In 28 patients, the CXR identified the etiology, and in 16 cases the CXR ruled out an intrathoracic cause. There were three patients whose H&P and CXR did not identify their cervical etiology. No patients had a thoracic etiology that was not identified by CXR. An algorithm was developed: If H&P fail to determine the etiology or to direct the evaluation, CXR is performed and followed by appropriate evaluation if positive. A negative CXR is followed with computed tomography (CT) of the neck from the skull base to thoracic inlet for right-sided UVFI and to the aortic triangle for left-sided UVFI. Other diagnostic studies are directed by signs and symptoms. A chest CT is not recommended unless there is clinical suspicion of a pulmonary or thoracic process. Key Words: Evaluation-Vocal fold immobility-Vocal cord paralysis.     

Vestibular vocal fold behavior during phonation in unilateral vocal fold paralysis

Voice quality in patients with vocal fold paralysis can be affected by several factors, such as the position of the paralyzed vocal fold, its degree of atrophy, the configuration of its free edge, and the level differences between both vocal folds. Depending on the related vocal deficiency the patient will attempt to compensate using different maneuvers, such as increment of vocal tract and neck muscle contraction to improve glottal closure. This is probably one of the reasons why ventricular folds are frequently requested. The objective of this study is to analyze the behavior of the homolateral and contralateral vestibular folds to delineate patterns of vestibular motion during sustained phonation, in cases of unilateral vocal fold paralysis.     

Vocal Cord Medialization by Transcutaneous Injection of Calcium Hydroxylapatite

Transcutaneous vocal cord augmentation has increasingly become the method of choice when treating causes of vocal cord insufficiency. Many substances have accompanied this technique, but they all have problems. One newer substance is calcium hydroxylapatite (CaHA). CaHA may produce fewer problems and offer a longer-lasting treatment. Twenty-one patients were treated in the Pacific Voice Clinic with trancutaneous injection of CaHA for vocal cord paralysis (n = 19) and vocal scarring (n = 2). Maximum phonation time (MPT) was the measure of vocal performance. An improvement was seen in 20 patients with the MPT, who improved from 4.6 seconds before treatment to 10.8 seconds at posttreatment of 3 months (n = 15). This improvement was maintained at 6 months (MPT = 12 seconds, n = 12). Follow-up was incomplete because of the terminal nature of some diagnoses and the large geographical area covered by the clinic. Three subjects had submucosal injection of CaHA (two resolving spontaneously). Two other patients had extrusion of the material. With short-term and medial-term follow-up on a small group of patients, encouraging results were seen with transcutaneous injection of CaHA for vocal cord augmentation.     

Long-term preservation of voice improvement following surgical medialization and reinnervation for unilateral vocal fold paralysis

In June of 1996, we reported improved functional voice results when reinnervation was combined with surgical medialization for unilateral vocal fold paralysis. In addition, it was noted that further wasting of the reinnervated vocal fold was prevented in 96% of these patients beyond 2 years' follow-up. The study reported here compares the long-term preservation of voice improvement achieved by surgical medialization alone with that resulting from combined medialization and nerve-muscle pedicle reinnervation. Further significant wasting of the paralyzed vocal fold with voice deterioration from that achieved by surgical medialization alone was noted between 6 months and 2 years postoperatively in 28% of patients, while only 4% of those undergoing combined reinnervation demonstrated this finding at a minimum of 2 years' follow-up.     

The Adjustable Laryngeal Implant

An adjustable laryngeal implant made of titanium has been developed for the treatment of unilateral vocal fold paralysis. The implant includes three parts: a plate that allows fixation to the thyroid cartilage, a block of titanium which includes the adjustable part, and a micrometric screw in the middle of the lateral side of the block, which moves the adjustable part. Precise medialization is accomplished by regulating the screw which also permits easy secondary adjustments, if needed in the future. This retrospective study assesses clinical outcomes of medialization laryngoplasty with the titanium adjustable implant, in patients with unilateral vocal fold paralysis. This study has the limitations of a retrospective study. However, preliminary results are encouraging. Analysis of subjective responses confirmed marked improvement in laryngeal function, speech, and swallowing. Objective voice analysis confirmed improvement in the aerodynamic measures. The adjustable laryngeal implant has many advantages including: precise medialization, ease of secondary adjustment, and preseveration of the mucosal wave. This implant is biocompatible, no migration is possible (it is fixed to the cartilage) and no extrusion of the implant has occurred. Titanium is magnetic resonance imaging (MRI)-safe.     

Relationship among glottal area, static supraglottic compression, and laryngeal function studies in unilateral vocal fold paresis and paralysis

In this study, we evaluated the relationship between laryngeal function measures and glottal gap ratio and normalized measures of supraglottic behaviors in patients with unilateral vocal fold paresis (UVFP). Thirty-one patients were found to have unilateral vocal fold paresis by videoendoscopy and laryngeal electromyography, and 13 controls participated in this study. Patients with UVFP demonstrated significantly larger glottal gap ratios (p = 0.016) than control subjects. The nonparalyzed or contralateral vocal fold was associated with significantly more static false vocal fold compression (p = 0.03) compared with the paralyzed vocal fold or with the controls. Patients with unilateral vocal fold paresis were divided into subgroups: those with normal or abnormal maximum phonation time, flow, or pressure measures. Smaller glottal gap ratios were identified in patients with normal maximum phonation times and flow measures. Greater false vocal fold activity was identified in unilateral vocal fold paresis patients with normal laryngeal function measures than in unilateral vocal fold paresis patients with abnormal measures. These findings suggest that some patients with documented unilateral paresis and glottal incompetence can compensate for vocal fold weakness such that their acoustic and aerodynamic measures are normal.     

Vocal fold paralysis secondary to cardiac countershock (cardioversion)

Application of electrical energy to the heart is effective in treating many dysrhythmias. There are, however, also disadvantages associated with cardioversion. Employment of external electrical current has been shown to induce epicardial and myocardial damage at the site of electrode application. We present the only case in the English literature of vocal fold paralysis in which the single identified associated event was cardioversion. In this case of temporary vocal fold paralysis, there was no invasive procedure to directly damage the nerve. Echocardiography of the patient revealed a large left atrium, placing the recurrent laryngeal nerve in an abnormal anatomic position where it was vulnerable to the electric current.