Thyrohyoid approach for vocal fold augmentation

OBJECTIVES: I performed a retrospective chart review to evaluate the patient tolerance and clinical results of a new technique for office-based vocal fold augmentation. METHODS: Ten patients undergoing the thyrohyoid approach for vocal fold augmentation were asked to rate their tolerance of the procedure using a 10-point rating scale (1 = "no problem" and 10 = "very uncomfortable"). The patients also filled out a quality-of-life survey (Voice Handicap Index-10) immediately before and 1 month after the procedure. I reviewed the preprocedure and postprocedure stroboscopic findings. The findings analyzed included changes in wave symmetry and glottal closure, and evidence of implant migration. RESULTS: All patients successfully underwent the procedure. The mean patient tolerance score was found to be 2.1. The average score on the Voice Handicap Index-10 improved from 21.3 before the procedure (SD, 9.23) to 7.5 after the procedure (SD, 5.77). These values were compared by use of a paired t-test, and the difference was found to be significant, with a p value of .01. The analysis of stroboscopic results revealed "improvement" or "no change" in the wave symmetry, "improvement" in glottal closure, and "no evidence of migration" after the procedure in all cases. CONCLUSIONS: The study findings demonstrate that the thyrohyoid approach can be used successfully in patients who need vocal fold augmentation, and that it is generally well tolerated.     

Homologous collagen substances for vocal fold augmentation

OBJECTIVES/HYPOTHESIS: Dysphonia resulting from failure of glottic closure during voicing is a difficult clinical problem. Recently developed homologous collagen compounds may be beneficial in treating this problem. The objectives of this thesis are to: 1) evaluate the potential site(s) of collagen graft placement in the human vocal fold, quantify the amount of graft material that can be injected into these sites, and determine how these sites are accessed by the currently available surgical tools for injection; 2) determine the effects of the superficial vocal fold implant on laryngeal vibratory patterns and characterize how the implant affects the forces required to bring vocal folds into an adducted position for vibration; and 3) evaluate the host response to two different forms of cadaveric collagen. STUDY DESIGN: Prospective laboratory. METHODS: Three separate experiments were undertaken: 1) Eight cadaver larynges were injected with collagen compounds through a 27-gauge needle. The amount of substance required to medialize the vocal fold and potential positions for graft placement were evaluated. 2) Six cadaver larynges were mounted on a stabilizing stand while airflow, vocal fold length, adduction forces, and abduction forces on the vocal folds were manipulated. Vibratory patterns before and after the injection of the vocal folds with solubilized collagen were assessed. 3) A nude mouse model was used to study the host response to two different exogenous collagen compounds. RESULTS: Solubilized collagen compounds could be injected reliably into the superficial layer of the lamina propria (SLLP), medial portion of the thyroarytenoid muscle, or lateral portion of the thyroarytenoid muscle. When injected superficially, significantly less material was required to displace the medial edge of the vocal fold to midline (P =.0001). When graft material was placed into the medial portion of the thyroarytenoid (TA) muscle, the forces required to bring the vocal fold into a position suitable for vibration were significantly reduced (P =.0106) and the vibratory patterns of the vocal folds were not impaired. Both AlloDerm(R) and Dermalogen(R) solubilized preparations of human dermal tissue were well tolerated in the nude-mouse model. Minimal inflammatory reaction occurred. Small amounts of graft material were identified histologically at the end of the 6-month study period. The graft material appeared organized and had been infiltrated with fibroblasts of host origin. CONCLUSIONS: Homologous collagen compounds can be reliably injected into the cadaveric human larynx. When the substances are injected into the medial portion of the TA muscle, immediately deep to the vocal ligament, they decrease the force of contraction needed to bring the vocal folds into a position adequate for phonation and have minimal affect on the vibratory patterns. These forms of homologous collagen are well tolerated. A small amount persists over a 6-month interval. These materials warrant further clinical trials in human subjects.     

Results of fascial augmentation in unilateral vocal fold paralysis

The objective of this study was to evaluate the effects on voice quality of augmentation by injection of minced fascia in patients with unilateral vocal fold paralysis. Preoperative and postoperative voice samples from 14 patients (6 men and 8 women; mean age, 59 years) were analyzed by computerized acoustic analysis and blinded perceptual evaluation. Statistically significant improvements were seen in perturbation measurements (jitter and shimmer), noise-to-harmonics ratio, and maximum phonation time. A panel of evaluators rated 10 of the 14 postoperative voices as normal or near-normal. Injection laryngoplasty with minced fascia offers a new, effective, well-tolerated, and inexpensive method to medialize a paralyzed vocal fold. The graft seems to survive well, as indicated by good vocal results with a follow-up ranging from 5 to 32 months.     

Clinical experience with injectable collagen for vocal fold augmentation

Injectable collagen appears to be safe and effective in treating glottic insufficiency. Fifty-four patients received vocal-fold injections of Zyderm Collagen Implant and their responses were followed for as long as 2 years. Videostroboscopy affords the best assessment of glottic function and correlates well with vocal quality. Maximum phonation time and transglottic airflow are the most sensitive measures of glottic efficiency; follow-up studies indicate that responses to treatment vary at 1 week, tend to stabilize by 3 months, and show only slight decrement over 1 year. One patient experienced a delayed hypersensitivity reaction, but it did not adversely affect his result. The use of cross-linked preparations of collagen should decrease the incidence of such responses. Treated patients were divided into diagnostic groups. Patients with bilaterally scarred vocal folds did not appear to respond optimally to collagen injection. Vocal rehabilitation was better if patients had at least one normal vocal fold. The best results occurred in patients with unilateral vocal fold paralysis and pre-existent bowing or atrophy did not affect these results. Collagen should be injected in the plane of the vocal ligament for best results; if the injection is too deep the implant is resorbed, and if too superficial, vocal-fold vibration is impaired.     

Rejection of injectable silicone “Bioplastique” used for vocal fold augmentation

A rare case of repeated granulomatous inflammation after silicone injection laryngoplasty for vocal fold immobility as well as its treatment by endoscopic approach is reported. The patient presented a right-sided vocal fold immobility after laryngeal trauma and remained dysphonic despite of logopedic voice therapy because of severe glottal insufficiency. An endoscopic transoral intrafold silicone injection was applied to improve the vocal function. Silicone granuloma inflammation was observed 8 days after the vocal fold augmentation. Oral broad-spectrum antibiotics and corticosteroids did not improve the inflammation. A cordotomy was performed to remove the silicone implant. After 3 months, a second endoscopic surgical intervention was necessary to remove a recurrent silicone granuloma. Eight months after the second surgical intervention, the inflammation had disappeared. An autologous fat injection to restore the glottal closure was performed successfully. Type IV contact allergy was excluded with an epicutaneous patch and scratch test with components of the silicone implant. Clinical and treatment observations are reported and the literature on complications of intrafold injected silicone for vocal fold augmentation is reviewed.     

Videostroboscopic assessment of unilateral vocal fold paralysis after augmentation with autologous fascia

Vocal fold augmentation by injection laryngoplasty is a simple and fast procedure. The aim of this prospective study was to assess the glottal closure and the travelling mucosal wave by videostroboscopic images after autologous fascia augmentation in unilateral vocal fold paralysis (UVFP) with a special reference to objective analysis of voice. A total of 14 UVFP patients with poor voice and open glottal gap were assessed by videostroboscopy, blinded perceptual evaluation of running speech and acoustical analysis of sustained vowel. Data were collected before the procedure and at a supplementary evaluation 5–32 months (mean: 13 months) after injection of autologous fascia deep into the paralysed vocal fold. Mean age was 59 years; there were eight women and six men. Frame-by-frame video analysis revealed that before the operation 10 out of 12 had large glottal gaps without any contact between vocal folds on phonation. After the procedure seven gaps were completely closed, four partly, and two had no mucosal contact in stroboscopic examination. Maximum gap between vocal folds decreased from 7.21 units to 1.65 units (paired t-test P<0.001). Mucosal wave amplitude symmetry and phase synchrony were present in most subjects with partial closure and phase synchrony in every patient with a proper glottic closure. A panel of listeners rated voice to be significantly better (P<0.01) ) after the procedure, and the improvement in acoustical parameters was also statistically significant (P<0.01). There was a good correlation between objective voice analysis and videostroboscopy. Residual glottal gap was the major reason for less than optimal postoperative voice. No signs of hampered mucosal wave were noticed. Videostroboscopy and objective voice analysis suggest that augmentation by autologous fascia does not induce scar or fibrous tissue in the subepithelial space. Slight over-correction should be attempted initially in order to accomplish sufficient augmentation. This might enhance complete glottic closure and improve the outcome.     

经鼻填充鼻中隔软骨修复眶内侧壁骨折

目的：探讨应用鼻内镜填充鼻中隔软骨,修复眶内侧壁骨折,经鼻做眼部手术的可能性。方法：选取眶内侧壁骨折患者11例（11眼）,术前检查均有不同程度的眼球内陷、复视、视力减退症状,行眼眶CT诊有眶内容物疝入筛窦并伴积液,其中6例内直肌肿胀。手术开始在内镜直视指引下,经鼻腔开放筛窦,摘除筛房,暴露骨折的纸板,将疝入物回纳眶内,鼻中隔软骨覆盖骨折区。结果：患者手术后全部治愈。双眼突出度相差≤1mm,平均0.11mm。视力较术前不改变或者略有改善。鼻内镜检查见筛窦术腔上皮化,填充的鼻中隔软骨无移动,无感染及排斥现象。结论：经鼻填充鼻中隔软骨修复眶内侧壁骨折方法简便,成功率高。自体鼻中隔软骨无排斥反应。     

Quality-of-life outcomes following laryngeal endoscopic surgery for non-neoplastic vocal fold lesions

Preservation of the vocal fold cover during laryngeal surgery should optimize vocal outcomes for patients with benign glottal lesions. The aim of this study was to evaluate changes in the quality of life, perceptual voice evaluation, and acoustic and aerodynamic measures of patients before and after endoscopic laryngeal microsurgery for true vocal fold cysts, polyps, and scarring. Preoperative and postoperative Voice Handicap Index (VHI) scores, Short Form 36 scores, and perceptual, acoustic, and aerodynamic voice measures were obtained prospectively from 42 patients who underwent phonomicrosurgery from February 2000 through May 2003. The mean (+/-SD) preoperative VHI was 49.6 +/- 21. The mean postoperative VHI score at a minimum of 3 months after surgery decreased to 26.8 +/- 21 (p < .001). When divided by lesion type, VHI scores improved significantly after surgery for vocal fold polyps and cysts. Although patients with vocal fold scarring demonstrated improvement in VHI scores after surgery, statistical significance was not achieved. For the entire group, the Short Form 36 scores were not significantly different from US norms either before or after operation. The acoustic data showed statistically significant decreases in jitter (2.05% to 1.26%), shimmer (7.06% to 4.03%), and noise-to-harmonics ratio (0.18 to 0.13) after surgery (p < .05) in female patients. The upper pitch limit increased after surgery in women (495.3 Hz to 654.9 Hz, p < .001). These results indicate that the voice-related quality of life and some acoustic parameters improve significantly for patients who have undergone laryngeal microsurgery for vocal fold cysts and polyps. Vocal fold scarring remains a difficult clinical problem with less favorable outcomes following surgical treatment in this patient set.