Vocal Process Avulsion

Vocal process avulsion is a rare condition in which laryngeal trauma causes a separation of the vocal process from the body of the arytenoid cartilage. Typically symptoms are dysphonia and shortness of breath during phonation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography are helpful in establishing this important and sometimes elusive diagnosis. Several treatment modalities have been reported with varying success. We report four new cases, review four cases reported previously by the senior author, and suggest approaches to diagnosis and optimal treatment of vocal process avulsion.     

Vocal Process Avulsion

Vocal process avulsion is a rare complication of intubation or external laryngeal trauma that can cause significant dysphonia. The vocal process develops independently from the body of the arytenoid cartilage, which results in a fusion plane that is vulnerable to trauma. The findings of vocal process avulsion may be subtle, and the relationship of the vocal process to the body of the arytenoid cartilage must be examined closely. Stroboscopy is critical in the evaluation. We describe three cases of vocal process avulsion encountered by the senior author (R.T.S.) over the last 5 years and discuss our approaches to evaluation and treatment. All cases were repaired endoscopically. However, we used three different techniques. These include chemical tenotomy with botulinum toxin, closed reduction with fat injection, and open reduction via cordotomy.     

Permanent medialization of the paralyzed vocal fold utilizing botulinum toxin and Gelfoam

The clinical picture of a paralyzed vocal fold often has the same appearance as a subluxated arytenoid, with anterior and medial displacement of the arytenoid and a foreshortened and lax vocal fold. Previous work by the authors has shown that a subluxated arytenoid may be permanently repositioned by reduction and selective injection of the intrinsic laryngeal musculature with botulinum toxin. The injection changes the forces within the larynx, allowing the arytenoid to be brought back to proper position on the cricoid cartilage. This concept has been extended to the paralyzed vocal fold. It has been noted that even a clinically paralyzed vocal fold has voluntary motor units that may still act on the arytenoid through residual action from the interarytenoid and synkinesis. These forces are significant enough to manipulate the arytenoid and, thus, the vocal fold, into its correct, adducted position. In this paper, the arytenoid is mobilized to free any fibrosis. The thyroarytenoid and lateral cricoarytenoid muscles are then injected to prevent any forward synkinetic pull on the arytenoid. Next, a Gelfoam injection medializes the vocal fold to create glottic closure. This rebalancing sufficiently positions the arytenoid, so that valvular function is permanently restored. In the ten patients studied for over 1 year, there was a 90% success rate as measured by videostroboscopy, phonation time, and V-RQOL analysis. There were no untoward complications. All the materials used are nonpermanent. The procedure does not limit other techniques from being performed at a later time.     

Arytenoid dislocation

Arytenoid dislocation is a common yet infrequently diagnosed complication of laryngeal trauma. It may result in various symptoms, including permanent dysphonia, although immediate voice change is not always present. Early reduction is the treatment of choice; however, late reduction is often successful in restoring voice. A high index of suspicion based on the history of the patient is necessary to recognize arytenoid dislocation. Thorough physical examination and objective tests are helpful in confirming this diagnosis.     

Mild Vocal Fold Paresis: Understanding Clinical Presentation and Electromyographic Findings

The implications of mild vocal fold hypomobility are incompletely understood. This study describes the clinical, electromyographic, and probable etiologic findings in patients who presented with complaints of dysphonia and whose physical examination revealed vocal fold paresis as a factor possibly contributing to their voice complaints. A retrospective chart review of all patients who presented to a tertiary laryngology referral center over a 13-month period, who had a clinical diagnosis of mild vocal fold hypomobility and who underwent laryngeal electromyography, were included in the study. A total of 22 patients completed the medical evaluation of their voice complaint. Of these patients, 19 (86.4%) were found to have evidence of neuropathy on laryngeal electromyography. The clinical picture indicated the following probable origins for the vocal fold paresis: goiter/thyroiditis (7/22 or 31.8%), idiopathic (4/22 or 18.2%), viral neuritis (4/22 or 18.2%), trauma (3/22 or 13.6%), and Lyme's disease (1/22 or 4.5%). This article describes the clinical entity of mild vocal fold hypomobility and associated flexible laryngoscopic, rigid strobovideolaryngoscopic, and laryngeal electromyographic findings.     

Unilateral recurrent laryngeal nerve paralysis: A re-examination

Re-examination of flexible fiberoptic videotaped laryngeal images of 39 patients with unilateral recurrent laryngeal nerve paralysis (URLNP) by four observer-judges revealed consistent findings of a unilaterally appearing shorter vocal fold with asymmetry of the arytenoid complex on the involved side. No previous similar experience in otolaryngological training or practice has been encountered. Multiple discrepancies between and among observer-judges regarding vocal fold positions during phonation were encountered. Possible explanations are discussed. The need for further investigation to determine the mechanics causing these differences is stressed. It is suggested that for the present, such terms as median, paramedian, and intermediate be used in teaching and in practice as generalities only.     

Effects of long-term intubation on vocal fold mucosa in dogs

A canine model was used to study effects of long-term intubation on vocal fold mucosa. Dogs' larynges were removed 5 weeks after a 7-day intubation period and were compared with control tissue. Intubation effects on vocal fold mucosa were highly variable. Most severe damage was observed posteriorly, at the presumed location of direct tube-mucosa contact. Effects judged to be less severe but still significant were noted in tissue anterior to this site. Morphometric analysis of the layers of the intubated mucosa revealed significant differences in epithelium, connective tissue, and glands, as compared with control tissue. Differences were also observed for blood vessels and nerves. Of particular clinical importance was evidence of damage along membranous, as well as cartilaginous, portions of the true vocal fold, and of damaged connective tissue and cartilage underlying epithelium which appeared normal. Implications of the findings for recovery from intubation, and for voice, are discussed.     

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.     

Laryngeal injuries after short-versus long-term intubation

Forty-five patients were seen over a 5-year period with laryngeal injuries following endotracheal intubation (ETI). The mean duration of ETI was 5.6 days (2 hours to 37 days). Patients intubated for less than 24 hours were most likely to present with a vocal fold immobility or an anterior glottic web. Long-term intubation was associated with the development of subglottic stenoses and granulomas. Patients with vocal fold immobility were seen more often after ETI for surgical reasons and had a significantly higher incidence of previous intubation and tobacco usage. Subglottic stenoses were seen in younger patients intubated for medical reasons and associated with nasogastric tubes and longer periods of intubation.     

Minifenestration Type I Thyroplasty Using an Expanded Polytetrafluoroethylene Implant

Several methods have been used to treat laryngeal incompetence, but no ideal technique has been identified. This paper describes a clinical experience with minifenestration type I thyroplasty using a new device made of expanded polytetrafluoroethylene (ePTFE). The device, a thin ribbon of ePTFE, is inserted through a 4-mm fenestration to produce vocal fold medialization. At our center, 26 of these devices have been implanted in the past 3 years. Good or satisfactory results were achieved in 96% of cases. Advantages of this technique include easy insertion of the implant, nominal cost and biocompatibility of the ePTFE device, ready availability of all instruments required for the procedure, and elimination of the need to perform arytenoid adduction.     

Comparison between thyroplasty type I andArytenoid rotation: a study of vocal fold vibration using excised human larynges

The purpose of this paper was to compare the vibration of the vocal fold submitted to Isshiki thyroplasty type I (TPI) to that of the contralateral one adducted by the arytenoid rotation (AR) technique. The vocal folds of ten human fresh excised larynges were medialized by TPI on one side and by rotation of the arytenoid on the contralateral side. Laryngeal vibration was artificially produced and was recorded by videostroboscopy. The images were subjectively and objectively analyzed. Subjective analysis included periodicity of vibratory cycles, features of the mucosal wave present on the TPI side, amplitude of vibration, and profile of free border of each vocal fold during the opening phase. Objective analyses were carried out on frame-by-frame digitalized images to determine amplitudes of vibrations and phase differences between the folds in three glottic regions (anterior, middle, and posterior). Subjective analysis revealed regular periodicity in 100% of the larynges, a decrease in the mucosal wave on the TPI side in 70%, reduction in amplitude in 30%, and a sigmoid profile of the free border on the TPI side in 80%. Objective analysis showed mean amplitude in the posterior glottic region on the TPI side significantly larger than that on the arytenoids rotation side and phase asymmetry in 90% of the larynges.     

A comparison of type I thyroplasty and arytenoid adduction

Glottal incompetence is a common laryngeal disorder causing impaired swallowing and phonation. The resultant voice has been characterized as weak and breathy with a restricted pitch range. Currently, medialization thyroplasty and arytenoid adduction are two of the surgical treatments for patients with glottal incompetence. However, few studies have evaluated the changes in objective measures of speech with type I thyroplasty and arytenoid adduction. In this study, 59 patients with glottal incompetence underwent either type I thyroplasty or arytenoid adduction. Acoustic (jitter, shimmer, and harmonics-to-noise ratio) and aerodynamic (airflow, subglottic pressure, and glottal resistance) measures were obtained both pre- and postoperatively. No significant differences were found among acoustic or aerodynamic measures for operation type. However, a significant pre/postsurgery effect was observed for translaryngeal airflow. In addition, no significant differences were found among the measures for patients with traditional compared with nontraditional operative indications. Patients who developed glottal insufficiency due to previous laryngeal surgery (e.g., vocal fold stripping) demonstrated no statistically significant improvement in acoustic or aerodynamic measures following thyroplasty or arytenoid adduction.     

Laryngeal sarcoidosis presenting as an isolated submucosal vocal fold mass

Sarcoidosis can affect the larynx as a manifestation of systemic disease or as isolated laryngeal involvement. Classically, laryngeal involvement affects the supraglottis, and less commonly the subglottis, and true vocal fold involvement is rare. The clinical course is often highlighted by frequent exacerbations and remissions that, when associated with vague complaints and constitutional symptoms, are probably the greatest contributor to delayed presentation and diagnosis. We describe an unusual case of sarcoidosis that presented after a long and protracted clinical course as an isolated submucosal vocal fold mass requiring deep biopsy for diagnosis. A review of the literature with emphasis on diagnosis, appropriate airway management, and treatment is presented.     

Determining the etiology of mild vocal fold hypomobility

The prevalence of mild vocal fold hypomobility is unknown. In a study by Heman-Ackah et al, vocal fold hypomobility in a population of singing teachers was found to be associated more frequently with vocal complaints than was the presence of vocal fold masses.¹ The etiology of mild vocal fold hypomobility has not been previously explored. In the present study, a retrospective chart review was performed of 134 patients who presented to a tertiary laryngology referral center over a 6-month period for evaluation of vocal complaints. Of the 134 patients, 61 (46%) were found to have mild vocal fold hypomobility previously undiagnosed by the referring otolaryngologist. Imaging studies and laboratory tests to evaluate for structural, metabolic, and infectious causes of the decreased mobility had been ordered. Forty-nine patients completed the work-up. Of these, 41 out of 49 (84%) were found to have imaging or laboratory findings that could explain the hypomobility. Thyroid abnormalities were found to be associated with vocal fold hypomobility in 21 out of 49 (43%) of those with a complete evaluation. Other causes of vocal fold hypomobility included idiopathic (8 of 49, 16%), viral neuritis (5 of 49, 10%), central nervous system abnormality (4 of 49, 8%), neural tumor (3 of 49, 6%), joint dysfunction (3 of 49, 6%), iatrogenic nerve injury (2 of 49, 4%), myopathy (2 of 49, 4%), and noniatrogenic traumatic nerve injury (1 of 49, 2%), This study shows that unilateral vocal fold hypomobility often is associated with a physiologic process, and a complete investigation to determine the etiology is warranted in all cases.     

Electrophysiologic monitoring of the recurrent laryngeal nerves may not predict bilateral vocal fold immobility after thyroid surgery

Two cases of bilateral vocal fold immobility (VFI) after identification and preservation of the recurrent laryngeal nerves (RLNs) required tracheotomy until vocal fold recovery. The first patient underwent thyroid surgery without preoperative or postoperative evaluation of the vocal folds, administration of postoperative intravenous steroids, or electrophysiologic monitoring of the RLNs, whereas the second patient underwent a thyroid procedure in which all of the aforementioned were executed. Preoperative and postoperative clinical evaluation of the RLNs is strongly suggested in patients undergoing thyroid surgery, especially revision surgery. Patients potentially undergoing total thyroidectomy should be counseled about the remote chance of airway obstruction and should be properly selected for this operation. Subclinical stretching of the RLNs or ischemia from the endotracheal tube cuff can result in unilateral VFI, and rarely bilateral VFI, requiring reintubation, tracheotomy, or vocal fold lateralization. Electrophysiologic monitoring may not always predict bilateral VFI.     

The Evolving Etiology of Bilateral Vocal Fold Immobility

In the past, bilateral vocal fold immobility (BVFI) occurred most commonly after thyroidectomy. However, no large series documenting the etiology of adult BVFI has been published within the past fifteen years. This study reviews the etiologic patterns of BVFI at our institutions. We compare BVFI from before and after 1980. We also review combined studies of unilateral vocal fold immobility (UVFI) to compare and unilateral versus bilateral etiologic trends. In comparison with previously published series, fewer cases of BVFI present today as a complication of thyroid surgery and more as the result of malignancies and nonsurgical trauma. Unfortunately, BVFI caused by malignancy is not usually an initial sign of local disease, but an ominous sign of recurrence or metastases. In comparing UVFI and BVFI we found that thyroidectomy causes a higher percentage of BVFI than of UVFI. Over one-third of UVFI cases were caused by neoplasm which further underscores the potential seriousness of immobile vocal folds and the need for careful investigation.     

Strobovideolaryngoscopic Findings in Singing Teachers

Professional voice users often present to otolaryngologists and laryngologists with specific voice complaints. The contributions of pathologic lesions to the patients' vocal complaints are not always clear on examination, and often, premorbid examinations of the larynx are not available for review. This study examines the incidence of laryngeal pathology among singing teachers. At a national convention of singing teachers, volunteers were recruited for a "free strobovideolaryngoscopic examination." All volunteers completed a detailed questionnaire of their vocal and medical history and underwent strobovideolaryngoscopic examination. Strobovideolaryngoscopic examinations were completed in 20 volunteers, 7 of whom had voice complaints and 13 of whom perceived their voices to be normal. Vocal fold masses were common among the asymptomatic singing teachers. Evidence of reflux laryngitis was a common finding among both symptomatic and asymptomatic singing teachers. Asymmetries in vocal fold hypomobility were more common among those with voice complaints than was the presence of vocal fold masses in the population studied.     

Recurrent Laryngeal Nerve Electrophysiologic Monitoring in Thyroid Surgery: The Standard of Care?

Reports in the literature suggest that the rate of transient and permanent vocal fold immobility (VFI) after thyroid surgery is 4% to 7% and 1% to 4%. The intraoperative use of nerve integrity monitors has been advocated to reduce the incidence of VFI during thyroid surgery. The purpose of this study was to compare postoperative VFI after unmonitored and monitored thyroid surgical procedures. The charts of 136 consecutive patients who underwent thyroid surgery from 1998 to 2003 were retrospectively surveyed. Fifty-four patients had total thyroidectomies, bringing the total recurrent laryngeal nerves (RLNs) dissected to 190. Three of 190 (1.6%) and 7 of 190 (3.7%) RLNs dissected had permanent and transient vocal fold dysfunction. Overall, 107 RLNs were unmonitored compared with 83 RLNs that were monitored. Unmonitored and monitored RLNs had a 4 of 83 (4.8%) versus 3 of 107 (2.8%) rate of transient VFI (P > 0.05). Unmonitored and monitored RLNs had a 1 of 107 (0.9%) versus 2 of 83 (2.4%) rate of permanent VFD (P > 0.05). Electrophysiologic RLN monitoring was not demonstrated in this study to reduce the incidence of transient or permanent VFI after thyroid surgery. Electrophysiologic RLN integrity does not always translate into clinical postoperative vocal fold mobility. Electrophysiologic RLN monitoring may support that the RLN was not severed in the patient with postoperative VFI.     

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.