Non-invasive assessment of benign vocal folds lesions in children by means of ultrasonography

Objectives

Flexible fiberoptic endoscopes have made pediatric laryngeal examinations an everyday practice, even though fiberoptic-flexible laryngoscopy (FFL) is not always well tolerated in young children because of limited cooperation. Laryngeal ultrasonography (LUS) has been applied to normal and pathological findings in infants and children, allowing the assessment of subglottic hemangiomas, laryngeal stenosis and paralysis. No previous study assessed benign vocal folds lesions by LUS in children. The aim of this study is to evaluate the possibility of LUS to detect benign vocal fold lesions in children by comparing the results of FFL in 16 children with those of LUS.

Methods

Sixteen children (9 males and 7 females) with a mean age of 7.5 ± 4.0 years were included in the study. Each child underwent FFL performed by a skilled phoniatrician and LUS performed blindly by an expert radiologist.

Results

On FFL bilateral vocal folds nodules were found in 9 patients, vocal fold cyst in 2 other patients, while in 2 children the vocal folds appeared normal. Laryngeal papyllomatosis, vocal fold polyp and vocal fold irregularity were found in only one patient. LUS enabled the diagnosis in all the 14 patients with vocal fold lesions. Bilateral hyperechoic lesions were visible in 10 patients, while hypoechoic lesions were found in three patients. No lesion were found in two children, while one patient presented with a monolateral hyperechoic lesion.

Conclusions

LUS was accurate, safe, well accepted and tolerated. LUS appears to be a useful diagnostic tool for supplementing FFL in the assessment of benign vocal fold lesions in children and may represent an interesting alternative in everyday clinical practice.     

Lamina propria of the mucosa of benign lesions of the vocal folds.

OBJECTIVE/HYPOTHESIS: To demonstrate a correlation between the duration and specific pattern of trauma of benign lesions of the vocal folds and their histopathologic appearance. Benign lesions of the vocal folds have various macroscopic appearances. Investigations demonstrate characteristic histopathologic features for three clinically well-defined lesions: 1) vocal fold polyps, 2) Reinke edema, and 3) vocal fold nodules. It is expected that additional histological stainings can contribute to additional insight into the pathophysiology of these lesions. STUDY DESIGN: Retrospective. METHODS: Histological stainings were used to study the constitution of the lamina propria of the mucosa: Verhoeff-van Gieson, Masson trichrome, alcian blue and alcian blue after pretreatment with hyaluronidase. RESULTS: Estimation of the age of a lesion was not possible. Specific observations: 1) accumulation of hyaluronic acid around vessels occurred uniquely in polyps and 2) transverse orientation of elastic fibers was more often seen in vocal fold nodules. Combinations of histopathologic findings were specific to the lesion. CONCLUSIONS: The additional stainings support our previous observations, but had no additional discriminating value in making a histopathologic diagnosis.     

Multidimensional assessment of vocal changes in benign vocal fold lesions after voice therapy

Objective

To evaluate through a multidimensional protocol voice changes after voice therapy in patients with benign vocal fold lesions.

Methods

65 consecutive patients affected by benign vocal fold lesions were enrolled. Depending on videolaryngostroboscopy the patients were divided into 3 groups: 23 patients with Reinke's oedema, 22 patients with vocal fold cysts and 20 patients with gelatinous polyp. Each subject received 10 voice therapy sessions and was evaluated, before and after voice therapy, through a multidimensional protocol including videolaryngostroboscopy, perception, acoustics, aerodynamics and self-rating by the patient. Data were compared using Wilcoxon signed-rank test. Kruskal–Wallis test was used to analyse the mean variation difference between the three groups of patients. Mann–Whitney test was used for post hoc analysis.

Results

Only in 11 cases videolaryngostroboscopy revealed an improvement of the initial pathology. However a significant improvement was observed in perceptual, acoustic and self-assessment ratings in the 3 groups of patients. In particular the parameters of G, R and A of the GIRBAS scale, and the noise to harmonic ratio, Jitter and shimmer scores improved after rehabilitation. A significant improvement of all the parameters of Voice Handicap Index after rehabilitation treatment was found. No significant difference among the three groups of patients was visible, except for self-assessment ratings.

Conclusion

Voice therapy may provide a significant improvement in perceptual, acoustic and self-assessed voice quality in patients with benign glottal lesions. Utilization of voice therapy may allow some patients to avoid surgical intervention.     

Benign lesions of the vocal folds: uniformity in assessment of clinical diagnosis

The names given to a number of benign lesions of the vocal folds are not well standardized and lead to difficulties in comparing treatment. In the present study photographs of benign lesions of the larynx were presented to groups of clinicians together with a questionnaire, and the answers analysed. The results show great variation between clinicians in interpretation and naming of these lesions. Definitions are suggested for different benign conditions in order to standardize the nomenclature.     

Videostrobokymographic analysis of benign vocal fold lesions

OBJECTIVES: Videostrobokymography (VSK) has recently been introduced. The aim of this study was to analyze vibratory patterns and objective parameters in various benign vocal fold lesions using VSK and to examine the efficacy of VSK in clinical applications. MATERIAL AND METHODS: Using VSK, we analyzed the vibration patterns of normal vocal folds, various benign lesions such as nodules, polyps, cysts and Reinke's edema and cases of unilateral vocal fold paralysis. We also calculated the objective parameters open quotient and asymmetric index and compared them with their mean values in normal controls. RESULTS: In nodules, polyps and cysts, the open quotient at the site of the lesion was similar to the mean value in the normal controls; however, on the other parts of the vocal folds, it was much larger than the normal mean value. In Reinke's edema, irregular and asymmetric vibrations were observed. The posterior area of the vocal folds showed larger open quotients than the anterior area. In unilateral vocal fold paralysis, irregular vocal fold vibration and incomplete closure of the vocal folds were documented. Much larger asymmetric indices were calculated for unilateral vocal fold paralysis than in normal controls or for other lesions. The asymmetric index may be a good quantitative parameter of vibration in patients with vocal fold paralysis. CONCLUSION: This study demonstrated that VSK could generate clear quantitative documentation of fine vibrations of vocal folds in many different types of benign lesion. VSK has the potential to be an effective tool for the quantitative analysis of vibratory patterns of vocal folds in clinical settings.     

Radiophonosurgery of benign superficial vocal fold lesions

OBJECTIVE: To conduct a prospective randomized controlled trial describing and investigating the efficacy and safety of radiosurgical excision of benign superficial vocal fold lesions. MATERIALS AND METHODS: Fifty patients with benign superficial vocal fold lesions (20 vocal nodules, 27 vocal polyps and three Reinke's oedema) who failed conservative therapy were included in the study. They were equally randomized into cold knife or radiosurgical excision. Clinical and voice assessments were done pre-operatively and after surgery. Voice analysis included a subjective visual analogue scale (VAS) and a perceptual assessment with a simplified version of the GRBAS scale (GRB) consisting of G (grade), R (roughness), and B (breathiness). Acoustic voice evaluation included jitter and shimmer. Post-operative voice therapy was provided for all patients. Complications, smoothness of post-operative recovery, and administration of analgesia were reported. RESULTS: Both groups experienced significant improvement in VAS, perceptual evaluation and acoustic analysis after surgery, with no evidence of significant differences between the cold knife and radiofrequency groups. The radiofrequency group showed a decrease of 17 per cent in the mean operative time when compared with the cold knife group, but this was not statistically significant. No evidence of a significant difference was noticed in the smoothness of post-operative recovery, administration of analgesia and complication rate. CONCLUSION: Radiophonosurgery opens a new therapeutic approach for patients with benign superficial vocal fold lesions. It combines the advantages of both cold knife and laser phonosurgery, being easy, safe, precise and effective, and having excellent tactile and haemostatic properties.     

喉良性增生性病变的嗓音学特点及治疗转归

目的 :探讨喉良性增生性病变对发声功能的影响及CO2 激光显微外科术后的转归特点。方法 :对2 92例喉良性增生性病变患者 (声带息肉、任克水肿、声带小结、囊肿、慢性肥厚性喉炎 )的流行病学、嗓音声学、形态及CO2 激光显微外科术后转归进行分析。结果 :声带小结患者均为青年女性 ,2 3.0 8%与职业有关 ;任克水肿为中老年患者。声带息肉及小结病变局限 ,手术仅涉及声带局部 ,术后改善明显 ,术后 1个月达正常状态 ;任克水肿患者术后 1个月改善明显 ,术后 3个月恢复最佳稳定 ;声带囊肿患者术后 1个月声音达最佳状态 ,但由于病变切除术后局部存在缺损 ,一定程度上影响预后 ;慢性肥厚性喉炎患者术后改善不满意。术后声门上代偿纠正均不明显。结论 :喉良性增生性病变主要累及声带被覆层 ,嗓音声障碍的程度及疗效与受累范围有关 ,激光显微外科手术可以保留良好结构及功能。除外科治疗外 ,还应及时矫正不良发声习惯等因素 ,以期获得最佳疗效。     

Anatomy and anatomopathology of benign vocal cord lesions

After 30 years of experience comprising more than 3000 suspension laryngoscopies, we are putting forward a classification of the main benign lesions of the vocal cords. Among the acquired group, we make a distinction between those caused by vocal overuse and abuse and those with a cause within the vocal cord. Congenital lesions are certainly more common than is usually thought. The hypothesis of a congenital origin would certainly justify a larger prospective study.     

A new instrument for intraoperative assessment of individual vocal folds

OBJECTIVES: Intraoperative assessment of vocal fold vibration during phonomicrosurgery performed under general anesthesia may enhance surgical decision-making. We therefore developed and bench-tested a new device we refer to as the aerodynamic vocal fold driver (AVFD). MATERIALS AND METHODS: The AVFD comprises a hand-held probe that uses airflow to drive individual vocal folds into phonatory-like vibration. This permits stroboscopic visualization of mucosal waves with simultaneous control of subglottal air pressure. In initial experiments to validate the technique, AVFD driven phonation and conventional whole-larynx phonation were compared using excised canine larynges (n = 14). RESULTS: Single vocal fold phonation using the AVFD and whole larynx phonation yielded similar, positive correlations between subglottal pressure and both amplitude and frequency of vibration. Experiments simulating vocal fold scar-related mucosal stiffening by subepithelial injection of fixative showed the expected elevation of phonation threshold pressures as measured with the AVFD. Likewise, unilateral tissue compression injury disrupted vocal fold vibration, and the AVFD was useful for quantifying improvement in the damaged vocal fold after repair with injection of cross-linked hyaluronic acid gel. CONCLUSIONS: These results show that this new instrument has the potential to provide novel and useful information for laryngeal experimentation and to improve phonosurgery.     

Factors predicting patient perception of dysphonia caused by benign vocal fold lesions

OBJECTIVES/HYPOTHESIS: To assess factors that may be predictive of patient perception of dysphonia severity, as quantified by the Voice Handicap Index (VHI) score. We hypothesize that 1) level of vocal demand; 2) auditory-perceptual evaluation of dysphonia severity; and 3) vocal function, as defined by phonatory glottal closure and mucosal wave vibration, are the most significant predictors of VHI score. STUDY DESIGN:: Retrospective review of 100 patients with benign vocal fold lesions. METHODS: Variables assessed for predictive value to VHI score are level of vocal demands, auditory-perceptual evaluation of dysphonia severity, integrity of mucosal wave vibration and phonatory glottal closure, lesion type, duration of current complaint, smoking, age, and sex. Harmonic to noise ratio was assessed in a subset of 50 patients. RESULTS: Patients with routine voice use had significantly lower VHI scores than those with more intensive (nonsinging/acting) vocal demands. Patients who quit smoking had greater VHI scores than those who currently smoke or never started. Patients with long-standing dysphonia tended to have lower VHI scores than those with shorter duration vocal complaints. Auditory-perceptual assessment of dysphonia severity and harmonic to noise ratio were weak predictors of VHI score. Age, sex, lesion type, phonatory glottal closure, and mucosal wave vibration were not significant predictors of VHI score. CONCLUSIONS: Patient perception of dysphonia severity is independent of many factors commonly assessed during the evaluation of voice disorders. It appears to be an important independent element in the assessment of the effect of a benign vocal fold lesion and critical to therapeutic decision-making.     

Phonomicrosurgery for benign vocal Fold lesions - our experience

Benign lesions of glottis creates stiffness of the vocal fold and inefficient glottal valve, aerodynamically effecting the vocal quality by preventing smooth vocal edge closure. Introduction of phonomicrosurgical techniques based on Hirano ’s principle of vocal fold epithelium have revolutionized results of voice surgery. Our experience in the management of benign vocal fold lesions by phonomicrosurgical techniques with pre and post operative stroboscopic, perceptual and computerized acoustic voice analysis is described.     

Learning curve for endoscopic evaluation of vocal folds lesions with narrow band imaging

IntroductionThe endoscopic methods are progressing and becoming more common in routine clinical diagnosis in the field of otorhinolaryngology. Relatively large amount of researches have proved high accuracy of narrow band imaging endoscopy in differentiating benign and malignant lesions within vocal folds. However, little is known about learning curve in narrow band imaging evaluation of laryngeal lesions.ObjectiveThe aim of this study was to determine the learning curve for the narrow band imaging evaluation of vocal folds pathologies depending on the duration of the procedure.MethodsRecords of 134 narrow band imaging that were analyzed in terms of the duration of the procedure and the accuracy of diagnosis confirmed by histopathological diagnosis were enrolled in the study. The narrow band imaging examinations were performed sequentially by one investigator over a period of 18 months.ResultsThe average duration of narrow band imaging recordings was 127.82 s. All 134 studies were divided into subsequent series of several elements. An evident decrease in time of investigation was noticed between 13th and 14th series, when the examinations were divided into 5 elements series, which corresponds to the difference between 65th and 70th subsequent narrow band imaging examination. Parallel groups of 67 examinations were created. Group 1 included 1st to 67th subsequent narrow band imaging examination; Group 2 – 68th to 134th narrow band imaging examinations. The non-parametric U Mann–Whitney test confirmed statistically significant difference between the mean duration of narrow band imaging examination in both groups 160.5 s and 95.1 s, respectively (p < 10^?7). Sensitivity and specificity of narrow band imaging examination in the first group were respectively: 83.7% and 76.7%. In the second group, these indicators amounted 98.1% and 80% respectively.ConclusionsA minimum of 65th–70th narrow band imaging examinations are required to reach a plateau phase of the learning process in assessment of glottis lesions. Analysis of learning curves is useful for the development of training programs and determination of a mastery level.