Unilateral arytenoid adduction improves voice in a patient with bilateral vocal fold immobility

Bilateral vocal fold immobility (BVFI) due to prolonged endotracheal intubation resulted in aphonia without any airway morbidity and was treated by several reconstructive procedures. Laryngeal reinnervation and silicone implantation failed to medialize one of those two fixed cords. Arytenoid adduction (AA) eventually achieved this goal. To select an optimal reconstructive procedure, a careful perusal of the history and head and neck examination including laryngeal electromyography, are necessary to determine the causes. AA procedure played an essential clinical indication in this study, not just an adjunct to the medialization laryngoplasty as usual. Since both the vocal cords positions were ranked as lateral positions subjectively, the full adduction for one of those two fixed vocal cords was performed without significant airway obstruction. The practice in this study provided an experience in correcting the voice in patients with BVFI. We need further experience to medialize the vocal cord in an appropriate magnitude since its counterpart may position variously and compromise the airway.     

An external approach without tracheotomy for submucosal cordectomy with laterofixation for bilateral abductor paralysis of the vocal folds

There are numerous surgical procedures now available to manage bilateral abductor paralyses of the vocal folds. These procedures have various success rates but mostly do not offer reliable and predictable postoperative results, and usually require ,tracheotomy. The technique described in this report is based on a trial study to obtain a safe airway for an affected patient and avoid tracheotomy, if possible. Submucosal cordectomy was used with lateral fixation of one vocal fold and preservation of the arytenoid. The procedure was performed by using continuous intravenous anesthesia, which does not require intubation of the patient's airway. Seven patients were operated with this technique with excellent postoperative results. The glottal airway was largely improved in all patients, with only minor temporary complications.     

Thyroplasty to improve the voice in patients with a unilateral vocal fold paralysis

Unilateral vocal fold paralysis may cause incomplete closure of the glottis and a poor voice. Thyroplasty is a relative new operation to improve the voice by‘medialization’of the paralysed vocal fold. In our series of 29 patients 24 (83%) were satisfied and 26 (90%) had a better voice. After the operation the voice was louder, clearer and easier to understand. The dynamic and melodic ranges on the phonetogram were wider; maximum loudness and maximum phonation time were improved. There were no complications during the follow-up of 4 months to 5 years. In the three patients whose voice was not improved, the vocal fold paralysis was due to local trauma and scarring     

Implantation of esterified hyaluronic acid in microdissected Reinke's space after vocal fold microsurgery: first clinical experiences

OBJECTIVE: In this pilot study are presented the first clinical experiences of the use of a resorbable bioimplant made of esterified hyaluronic acid inserted in the microdissected superficial layer of the lamina propria (SLLP), also called Reinke's space, after a flap excision procedure for a benign vocal fold lesion. Laryngeal and vocal evolution of implanted patients are depicted and discussed. STUDY DESIGN: Eleven bio-implants have been inserted in microdissected SLLP of 11 cases presenting with benign vocal fold lesions. The surgical procedure consisted of the excision of primary lesion by a microflap technique immediately followed by implantation of esterified hyaluronic acid in Reinke's space. METHODS: All patients underwent rigid laryngoscopy and a microsurgical procedure under general anesthesia. The cordal lesion was treated with cold instrumentation of Bouchayer (7 cases) or with a mixed technique using CO(2) laser (4 cases). After the classical freeing-up of Reinke's space and the creation of a mucosal flap, a few fibers of esterified hyaluronic bioimplant are gently arranged in Reinke's space before redraping the ligament and closing the cordal incision with a few drops of fibrin glue. Laryngeal and vocal assessments were performed pre- and postoperatively in all patients using videostroboscopy as well as perceptual and objective voice evaluation. All patients were followed in a longitudinal manner: between two and five postoperative evaluations were performed. The longest follow-up was 19 months and the shortest 2 months. RESULTS: All cases exhibited postsurgical improvement of the pliability of the SLLP. None of them developed an adverse scarring process. Improvement of SLLP's pliability was maintained in time in all cases. Vocal improvement was observed in all. Temporary inflammation was noted in one case. There were no serious adverse effects apparent during the follow-up period. CONCLUSION: Bio-implantation of esterified hyaluronic acid in Reinke's space is technically easy and well tolerated. All treated cases exhibited postoperative good pliability of the SLLP compared with their preoperative evaluation.     

Cytoskeleton of cells in vocal fold macula flava unphonated for a long period

Cells in the maculae flavae (MFe) are inferred to be involved in the metabolism of extracellular matrices of the human vocal fold mucosa. The latest research has supported the hypothesis that the tension caused by phonation (vocal fold vibration) regulates the behavior of these cells in the MFe of the human vocal fold. Tensile and compressive strains have direct effects on cell morphology and structure including changes in cytoskeletal structure and organization. Cytoskeletons are one of the structures which play a role as mechanoreceptors for the cells. The microstructure of the intermediate filaments and the expression of their proteins were investigated regarding the cells in the MFe of the human vocal fold unphonated over a decade. The adult vocal fold mucosa of a 64-year-old male with cerebral hemorrhage unphonated for 11 years was investigated by immunohistochemistry and electron microscopy. The intermediate filaments in the cytoplasm of the cells had become fewer in number. And the expression of their characteristic proteins (vimentin, desmin, GFAP) was also reduced. The results of this study are consistent with the hypothesis that mechanotransduction caused by vocal fold vibration could possibly be a factor in regulating the function and fate of the cells in the MFe.     

Functional outcome of vocal fold medialization thyroplasty with a hydroxyapatite implant

OBJECTIVES: Unilateral vocal fold paralysis can cause a persistent incomplete glottal closure during phonation, resulting in impaired voice function. The aim of this study was to evaluate functional results of medialization thyroplasty using a hydroxyapatite implant (VoCoM). STUDY DESIGN: Prospective observational cohort study. METHODS: Between 1999 and 2003, a total of 26 patients (19 men, 7 women) undergoing medialization thyroplasty using a hydroxyapatite implant because of unilateral vocal fold paralysis were enrolled in the study. To evaluate voice function, the following parameters were measured preoperatively and postoperatively: mean fundamental frequency, mean sound pressure level, frequency and amplitude range (voice range profile), and maximum phonation time. A perceptual assessment of hoarseness was conducted using the Roughness, Breathiness, Hoarseness scale. Furthermore, the magnitude of voice related impairment of the patient's communication skills was rated on a 7-point scale. A combined parameter called the Voice Dysfunction Index (VDI) was used to rate vocal performance. RESULTS: All patients showed a statistically significant improvement in the VDI, in perceptual voice analysis, in maximum phonation time, and in the dynamic range of voice. One patient experienced a postoperative wound hemorrhage as a minor complication. No further complications or implant extrusions were observed. CONCLUSIONS: Medialization thyroplasty using a hydroxyapatite implant is a secure and efficient phonosurgical procedure. Voice quality and patient satisfaction improve significantly after treatment.     

Imaging of the calf vocal fold with high-frequency ultrasound

Objectives/Hypothesis: High‐frequency ultrasound imaging offers the potential for assisting in the diagnosis and treatment of vocal fold pathology if it allows aspects of vocal fold microstructure to be visualized noninvasively. The objective of this study was to assess the ability of high‐frequency ultrasound to image vocal fold anatomy and injected biomaterials. Study Design: The vocal folds of two excised calf larynges were imaged ex vivo and compared with corresponding histological sections. Methods: High‐frequency ultrasound imaging was performed under saline submersion using 40 and 50 MHz transducers, and corresponding cryostat cross‐sections were stained with H&E, Trichome, and Verhoeff's Van Gieson stains. Results: The epithelial surface, lamina propria, and underlying muscle were easily identified with the high‐frequency ultrasound as verified with histological sections representing each imaged region. The arytenoid cartilage vocal process can also be clearly distinguished from the surrounding tissue, as can the full extent of injected biomaterials within the superficial lamina propria. Useful ultrasound resolution was obtained to depths of at least 10 mm within the tissue with the 40 MHz transducer. Conclusions: This preliminary study demonstrates the capability of high‐frequency ultrasound to image the layered anatomy of the calf vocal fold and to discern materials injected into the superficial lamina propria, indicating that this technology holds a strong potential for use in phonosurgery.     

Videostrobokymography: a new method for the quantitative analysis of vocal fold vibration

OBJECTIVES: To develop a new analysis method for the quantitative assessment of vibration of the vocal folds, using conventional videostroboscopic image data. METHODS: We used prerecorded videostroboscopic images to evaluate quantitatively the vibration of the vocal folds. Successive images were converted as digital images by means of an image-grabbing board, processed for analysis, and reconstructed as kymograms by rearranging the same lines of all processed images along the time axis. RESULTS: We developed a new technique for evaluating the vibration of the vocal folds. The vibrations of multiple vocal fold regions were easily and objectively evaluated by this technique. The objective parameters, such as open quotient and asymmetry index, could be obtained easily using this technique. CONCLUSIONS: Videostrobokymography demonstrated objectively the vibrations of several vocal fold regions at the same time. This technique has the potential to be a new tool to analyze and monitor the pathological changes and treatment results of vocal fold movement in a more refined quantitative fashion, using videostroboscopic images.     

Changes of sleep-disordered breathing after laryngeal surgery in patients with bilateral vocal fold paralysis

Snoring is the most obvious symptom of sleep-disordered breathing (SDB). Vibratory sound usually originates from the pharynx; however, in some circumstances, the narrowing of glottic structures can also cause nighttime breathing noise. This clinical study investigated the role of laryngeal obstruction in patients with SDB. Nine female patients with paralysis of bilateral vocal folds were enrolled in this study. All the patients received unilateral laser arytenoidectomy as the only treatment. Nocturnal polysomnography (PSG) was performed at baseline and 6 months after the operation. Parameters of PSG including the respiratory disturbance index (RDI) and snoring index (SI) were recorded, as well as the subjective Epworth Sleepiness Scale (ESS). Before surgery, six patients (66.6%) were identified as having obstructive sleep apnea (OSA, RDI>5). After the operation, the SI improved significantly (P=0.02). The RDI (P=0.07) and ESS (P=0.11) showed no significant improvement. The success rate of surgery in OSA patients was 66% (4/6) according to the criteria of a greater than 50% reduction of the preoperative RDI and less than 20 events per hour. The mechanism, outcomes and causes of failure are discussed in this unusual larynx-related SDB.     

Improvement of respiratory compromise through abductor reinnervation and pacing in a patient with bilateral vocal fold impairment

Objectives/Hypothesis.

To determine whether respiratory compromise from bilateral vocal fold impairment (paralysis) can be objectively alleviated by reinnervation and pacing.

Methods.

A patient with paramedian vocal folds and synkinesis had a tracheotomy for stridor after bilateral laryngeal nerve injury and Miller Fisher syndrome. One posterior cricoarytenoideus (PCA) received a nerve‐muscle pedicle fitted with a perineural electrode for pacemaker stimulation. The airway was evaluated endoscopically and by spirometry for up to 1 year.

Results.

Bilateral vocal fold patency during quiet breathing was reversed to active vocal fold adduction during tracheal occlusion. Peak inspiratory flows (PIFs) were significantly higher (P < .001) after reinnervation. PIFs and glottic apertures increased further under stimulation (42 Hz, 1–4 mA, 42–400 μsec). although the differences were not significant.

Conclusions.

Based on our preliminary data, PCA reinnervation and pacing offer promise for amelioration of respiratory compromise after paradoxical adduction in bilateral vocal fold impairment. Laryngoscope, 2010