Analysis of voice function following autologous fat injection for vocal fold paralysis.

OBJECTIVE: This study demonstrates that intravocal fold injection of autologous fat obtained by liposuction technique is simple, and the functional results durable for patients with unilateral vocal fold paralysis due to injury to the recurrent laryngeal nerve. STUDY DESIGN: 41 patients with unilateral paralysis of the vocal fold due to injury to the recurrent laryngeal nerve received intravocal fold injection of autologous fat. Autologous fat, harvested from the lower abdomen by liposuction technique, was filtered out and injected through a needle into the vocal fold by using endolaryngeal microsurgery. Clinical follow-up after the injection was carried out from 1 month to 2 years. RESULTS: Voice function dramatically improved compared with the parameters examined before the operation. Vocal function continued to improve as time passed during the second year after injection. CONCLUSIONS: Intravocal fold injection of autologous fat obtained by liposuction technique is simple, and the functional results durable for patients with unilateral vocal fold paralysis due to injury to the recurrent laryngeal nerve. SIGNIFICANCE: The effectiveness continued for more than 2 years in most patients.     

Vocal fold injection of collagen for unilateral vocal fold paralysis caused by chest diseases.

BACKGROUND: Patients having malignant chest diseases sometimes suffer from vocal fold paralysis. Treatment for vocal fold paralysis is important for such patients, because vocal fold paralysis causes lack of the versatility of the human voice which is essential for our communication. METHODS: Seventeen patients suffering from unilateral vocal fold paralysis were treated with vocal fold injections of collagen. Three patients received twice, and 20 treatments were conducted. A flexible bronchofiberscope was used under local anesthesia in order to observe the whole procedure of vocal fold injection. Using an injector and a long needle, collagen was injected with transcutaneous technique mainly through the cricothyroid membrane. The amount of collagen was determined with bronchoscopic findings. RESULTS: During and after treatment, no complication was observed. Of 20 treatments, a marked improvement was observed in 8, and moderate improvement was observed in 9 treatments. CONCLUSIONS: Vocal fold injection of collagen is a very useful and safe treatment for unilateral vocal fold paralysis caused by chest diseases.     

Videostroboscopic findings in unilateral superior laryngeal nerve paralysis and paresis.

OBJECTIVES: Our aim was to present laryngovideostroboscopic findings in unilateral superior laryngeal nerve paresis and paralysis. STUDY DESIGN AND SETTING: Retrospective case review, academic voice clinic. METHODS: Blinded retrospective review of videostroboscopic recordings from cases confirmed by laryngeal electromyography. RESULTS: Three cases of unilateral superior laryngeal nerve paresis and paralysis were identified. At rest, there were no common abnormal laryngeal findings. Upon phonation, common findings were ipsilateral vocal fold bowing and shortening, vocal process height asymmetry with the ipsilateral vocal process overriding the normal, and ipsilateral hyperadduction of the false vocal fold. CONCLUSIONS: The common features noted in these cases of laryngeal electromyography-proved uSLNp could be used to make a presumptive diagnosis of this disorder.     

Vocal fold augmentation with calcium hydroxylapatite.

OBJECTIVES: Voice disorders affect more than 3% of the general population. Vocal fold atrophy is a part of the normal aging process, with up to 60% of 60-year-old individuals displaying evidence of glottal insufficiency. A safe, effective, and durable substance for injection augmentation of the vocal folds is not currently available. The purpose of this investigation was to describe our preliminary experience with calcium hydroxylapatite (CaHA) for vocal fold augmentation. METHODOLOGY: All patients undergoing injection augmentation of the vocal folds with CaHA between January 1, 2002 and June 1, 2003 were prospectively evaluated. Data concerning indications, technique, functional outcome, and complications were collected. In addition, the larynx donated from a woman who underwent vocal fold augmentation with CaHA and subsequently died from terminal cancer was histologically examined. RESULTS: A total of 39 vocal folds in 23 individuals were injected with CaHA. The mean age of the cohort was 62. Fifty-two percent were male. The indications for augmentation were unilateral vocal fold paralysis (9/23), unilateral vocal fold paresis (5/23), presbylarynx (3/23), Parkinson's (3/23), bilateral vocal fold paresis (2/23), and abductor spasmodic dysphonia (1/20). There were no adverse reactions. All individuals reported improvement on a self-administered disease-specific outcome measure (P < 0.001). The pathology from the donated larynx 3 months after injection revealed intact CaHA spherules in good position with a minimal, monocellular inflammatory reaction to the gel carrier and no evidence of implant rejection. CONCLUSIONS: Initial experience with vocal fold augmentation using CaHA is promising. Long-term safety and efficacy needs to be established.     

Results of ansa to recurrent laryngeal nerve reinnervation.

OBJECTIVE: We sought to describe the results of ansa cervicalis to recurrent laryngeal nerve (ansa-RLN) reinnervation for unilateral vocal fold paralysis. STUDY DESIGN: A chart review was performed on patients undergoing ansa-RLN reinnervation for unilateral vocal cord paralysis at a tertiary care center. Patient perceptions of preoperative and postoperative voice quality was surveyed. Acoustic and visual parameters were assessed from videostroboscopy. RESULTS: From a total of 25 study patients, 15 patients underwent both preoperative and postoperativ video stroboscopies. In stroboscopies within 6 months, the average improvement in overall severity, roughness, and breathiness was 69, 79, and 100 percent, respectively. In stroboscopies after 6 months, the average improvement in overall severity, roughness, and breathiness was 63, 66, and 100 percent, respectively. Postoperatively, all patients had reinnervation of the vocal fold. CONCLUSIONS: Voice outcomes were improved in patients with preoperative and postoperative stroboscopies. SIGNIFICANCE: Ansa-RLN reinnervation should be considered as a treatment for unilateral vocal fold paralysis.     

Unilateral vocal fold paralysis: causes, options and outcomes.

BACKGROUND: This study presents the current aetiology of and management options for vocal fold paralysis. METHODS: One hundred and eight patients with unilateral vocal fold paralysis, managed by The Sydney Voice Clinic from 1989 to 1996, are reviewed. Aetiology of the palsy was classified as iatrogenic (45 of 108), idiopathic (36 of 108) and other defined causes (27 of 108). Nineteen patients were observed with the rest being managed with speech therapy alone (38 of 108), surgery (24 of 108) or surgery with adjuvant speech therapy (27 of 108). Surgical techniques included vocal fold augmentation (n = 43), thyroplasty (n = 20) and laryngeal re-innervation (n = 12). RESULTS: Overall 78 of 108 patients had restoration of near normal to normal voice with an additional 14 attaining a very good voice or better (voice outcome <2). CONCLUSIONS: Early intervention for symptomatic patients was found to be rewarding and safe. Vocal fold augmentation with autologous fat was particularly successful in achieving sustained improvement of voice.     

Long-term histological outcomes of injected autologous fat into human vocal folds after secondary laryngectomy.

OBJECTIVE: To histologically evaluate the long-term outcomes of autologous fat grafts after injection laryngoplasty in the human larynx. STUDY DESIGN AND SETTING: We injected liposuctioned fat for vocal fold augmentation in patients with vocal fold paralysis. We suctioned autologous fat from the low abdomen with an 18-G disposable needle and a 20-mL disposable syringe under negative pressure. This is different from the conventional liposuction technique and avoids the use of special equipment. In this article, we report the histological evaluation of 2 patients (patient 1: 12 months, patient 2: 41 months) who required total laryngectomy after autologous fat injection into the vocal folds. RESULTS: Histological examination revealed normal-appearing viable adipocytes with minimal inflammatory response in both patients. CONCLUSIONS: Our liposuctioned autologous fat injection histologically offered long-term improvement in patients with impaired glottal closure from vocal fold paralysis.     

Intracordal injection increases glottic closing force in recurrent laryngeal nerve paralysis.

Glottic closing pressure during swallowing was measured in the cat with a catheter pressure transducer to study the effectiveness of intracordal injection in increasing glottic pressure in unilateral recurrent laryngeal nerve paralysis. Swallows were elicited by pouring water into the pharynx while the animal was under light anesthesia with ketamine. Peak pressure of the glottic closure for the control group during deglutition was 68.0 +/- 10.5 mm Hg (mean +/- standard deviation). Peak pressure decreased to 22.0 +/- 3.6 mm Hg just after sectioning of the unilateral recurrent laryngeal nerve, and rose to 39.8 +/- 8.3 mm Hg by silicon injection into the paralyzed vocal fold. In a study of chronic cases 1 month or more after unilateral recurrent laryngeal nerve section, peak pressure was 49.1 +/- 23.4 mm Hg, and varied widely from 21 to 92 mm Hg because of differences in the position of the paralyzed vocal fold and the degree of compensation by the unaffected vocal fold. In the group that had the paralyzed vocal fold fixed in the median position, peak pressure was almost the same as that of the control group. When the paralyzed vocal fold was fixed in either the paramedian or lateral position, peak pressure was 33.3 +/- 7.0 mm Hg. This value was significantly elevated to 45.8 +/- 10.4 mm Hg by injection of silicon, though it remained lower than that of the control. These results suggest that the decrease in glottic closing force during swallowing as a result of unilateral recurrent laryngeal nerve lesion is compensated for by the unaffected vocal fold to some degree and is improved by intracordal injection.     

UNILATERAL VOCAL FOLD PARALYSIS: CAUSES,OPTIONS AND OUTCOMES

Background : This study presents the current aetiology of and management options for vocal fold paralysis. Methods : One hundred and eight patients with unilateral vocal fold paralysis, managed by The Sydney Voice Clinic from 1989 to 1996, are reviewed. Aetiology of the palsy was classified as iatrogenic (45 of 108), idiopathic (36 of 108) and other defined causes (27 of 108). Nineteen patients were observed with the rest being managed with speech therapy alone (38 of 108), surgery (24 of 108) or surgery with adjuvant speech therapy (27 of 108). Surgical techniques included vocal fold augmentation (n = 43), thyroplasty (n = 20) and laryngeal re-innervation (n = 12). Results : Overall 78 of 108 patients had restoration of near normal to normal voice with an additional 14 attaining a very good voice or better (voice outcome < 2). Conclusions : Early intervention for symptomatic patients was found to be rewarding and safe. Vocal fold augmentation with autologous fat was particularly successful in achieving sustained improvement of voice.     

Impact of laryngeal paralysis and its treatment on the glottic aperture and upper airway flow characteristics during exercise

Patients with unilateral vocal fold paralysis occasionally report shortness of breath during exercise. This symptom may persist in some patients after medialization thyroplasty. A review of the literature revealed no study that objectively evaluated laryngeal dynamics or airway flow characteristics during exercise after medialization thyroplasty for unilateral laryngeal paralysis. This study evaluates glottic aperture size and configuration as well as upper airway flow characteristics during exercise in 16 subjects. Six patients who underwent medialization thyroplasty for unilateral vocal fold paralysis were compared with 10 healthy control subjects. During a standardized exercise protocol on an incremental ergometer (bicycle type), real-time videolaryngoscopy was obtained and correlated in a synchronized fashion with maximum-effort respiratory efforts at the beginning, midpoint, and end of the exercise period. Direct calculations of glottic size during various phases of the exercise period were performed from digitized images. These data were correlated with inspiratory flow data for each patient. Patients with laryngeal paralysis demonstrated smaller mean glottic areas and lower peak inspiratory flow rates than controls both at rest and during all phases of the exercise period. This study suggests that after treatment of unilateral laryngeal paralysis with medialization thyroplasty, inspiratory flow rate and glottic area are significantly less than in normal controls.     

The Use of Polydimethylsiloxane for Injection Laryngoplasty

BACKGROUND: Injuries of the recurrent laryngeal nerve with consecutive vocal cord paralysis is a typical complication in chest, esophageal, thyroideal, and neck surgery. Glottic insufficiency secondary to such a lesion can be treated by endolaryngeal vocal cord augmentation (injection laryngoplasty). Many different substances have been used, often showing complications or disadvantages. This study reports on the use of injectable polydimethylsiloxane (PDMS), with special regard to the long-term results. METHODS: In this prospective study, 21 patients with unilateral vocal cord paralysis underwent injection laryngoplasty using PDMS at a volume of 0.5-1.0 ml. Preoperatively, 6 weeks and 12 months after the injection the following parameters concerning patients' voice were evaluated: Glottic closure by videolaryngostroboscopy, maximum phonation time, voice range, voice dynamic, jitter, shimmer, noise-to-harmonic-ratio, and roughness, breathiness, and hoarseness (RBH). In addition, patients were asked to give their own evaluation of how satisfied they felt with their voice and of the handicaps it caused them. RESULTS: Postoperatively an improvement was evident in all the parameters that were investigated, and this significant improvement was still in evidence for most of the parameters more than one year after the injection. In our study no complications were observed more than one year after injection. CONCLUSION: PDMS is a safe substance for injection laryngoplasty in unilateral vocal cord paresis. Objective and subjective parameters confirm its effectiveness. It is suitable for obtaining satisfying results in the reestablishment of the patient's voice and communication ability.     

Management of bilateral vocal fold paralysis: experience at the University of Athens.

The treatment of patients with vocal fold paralysis presents a challenge to the otolaryngologist-head and neck surgeon. Many techniques have been proposed to manage individuals with unilateral or bilateral vocal fold paralysis. We herein describe the experience of our department in dealing with bilateral vocal fold paralysis. At the University of Athens, patients presenting with symptomatic bilateral paralysis are treated with a posterior cordectomy by using the CO2 or KTP-532 laser. During the last 5 years, we have treated 20 patients (8 men and 12 women) presenting with symptomatic bilateral vocal fold paralysis. For augmentation of the glottic airway, a modification of Kashima's cordotomy was used, completing a partial posterior cordectomy of one or both true and false vocal folds with the CO2 laser (15 patients) and the KTP-532 laser (5 patients). An elective tracheotomy was done before the cordotomy. Complications, such as infection, stridor, or dyspnea, were minimal. Although no objective voice analysis was performed, all patients were able to communicate without any phonation device and were satisfied with the result of the surgery. When compared with other techniques, the advantages offered by the posterior cordectomy included rapidity and simplicity in concept, reliability of outcome, short hospitalization, low risk of complications, and the possibility for revision when necessary (posterior cordectomy). From the successful postsurgical results of this study, it can be concluded that the posterior cordectomy is a reliable treatment option for the management of patients with bilateral vocal fold paralysis.     

Clinical restoration of voice function after loss of the vagus nerve

One hundred eleven patients with unilateral vocal cord paralysis underwent Teflon® injection for the rehabilitation of laryngeal function. The most common etiology was vocal cord paralysis after surgical treatment of thoracic abdominal aortic aneurysms, which accounted for 36.9% of patients. Of the 111 patients, 85% had improved voice function after Teflon® injection. Two patients developed airway obstruction secondary to edema and required temporary tracheostomy. Twenty-four patients with paralysis after aneurysm surgery were injected acutely with no morbidity and immediate restoration of voice function. We now advocate Teflon® injection in patients with vocal cord paralysis after thoracic aneurysm surgery in the immediate convalescent period to restore voice function and lessen pulmonary complications.     

Bilateral congenital vocal cord paralysis: a 16-year institutional review.

OBJECTIVE: To review the management and outcome of bilateral congenital true vocal cord paralysis in 22 patients treated over a 16-year period and to review the role of tracheostomy in these patients. DESIGN: Retrospective chart review. SETTING: Pediatric tertiary hospital. PATIENTS: Twenty-two pediatric patients diagnosed with bilateral congenital true vocal cord paralysis. INTERVENTIONS: Flexible or rigid diagnostic evaluation, tracheostomy, and vocal cord lateralization procedures. MAIN OUTCOMES MEASURES: Vocal cord recovery and decannulation. RESULTS: With a mean follow up of 50 months, 15 of 22 patients (68%) with bilateral vocal cord paralysis required tracheostomy for airway securement. Of the 15 tracheotomized patients, 10 were successfully decannulated (8 had spontaneous recovery, whereas 2 required lateralization procedures). Eleven of these patients with tracheostomy had comorbid factors, including neurologic abnormalities (midbrain/brainstem dysgenesis, Arnold-Chiari malformation, global hypotonia, and developmental delay). Of the 7 patients not requiring tracheostomy, 6 recovered vocal cord function (86%). CONCLUSION: In our series of 22 patients with bilateral vocal cord paralysis, 14 had spontaneous recovery of function. Patients managed with tracheostomy were noted to have a high incidence of comorbid factors. In this series, recovery rates were found to be higher in nontracheostomized patients than in tracheostomized patients. Patients can be carefully selected for observation versus tracheostomy at the time of diagnosis based on underlying medical conditions.     

Laser tenotomy and vocal process resection for bilateral midline vocal fold fixation

Background: The present retrospective study presents the outcomes of a group of 21 patients with laryngeal obstruction caused by bilateral vocal fold fixation. All of these patients were treated by laser assisted muscle tenotomy and vocal process resection ? a modification of the technique described by Michael and Eugene Rontal in 1994. 1 Methods: Between January 1997 and March 2002 the senior author performed muscle tenotomy and vocal process resection for bilateral vocal fold fixation on 21 patients. Results: The mean follow‐up time was 2.3 years. The technique was successful in achieving an adequate airway and good voice with no aspiration in every case. Conclusions: Laser assisted muscle tenotomy and vocal process resection is a proven treatment for bilateral medial vocal fold fixation with the provision of a good airway, good voice and the avoidance of aspiration.     

Diplophonia in unilateral vocal fold paralysis and intracordal cyst

Diplophonia is the production by the voice of 2 separate tones through quasiperiodic variations in the vocal fold vibration (Ward PH, Moore GP. Ann Otol Rhinol Laryngol 1969;78:771-7). Clinically, diplophonia can be observed in patients with unilateral vocal fold paralysis with incomplete glottal closure and a mass lesion of the vocal fold, intracordal cyst, and granuloma (Kiritani S, et al. Ann Bull RILP 1991;25:55-62; Hirano M, et al. Ann Otol Rhinol Laryngol 1989;98:791-5). In this study we report 16 subjects with unilateral vocal cord paralysis or an intracordal cyst characterized perceptually by diplophonia. Diplophonia during tension imbalance may occur after surgery and is characterized by an improved perceptual score, a reduced number of vibratory cycles in each quasiperiodic waveform, and a reduced occurrence rate of the diplophonic waveform. During mass imbalance, no diplophonia occurred after surgery. Regarding the relationship of diplophonia with glottal condition at production of stops, in our study diplophonia varied significantly according to the different phonologic environments of stops during tension imbalance. We presume that there is a close relationship between the occurrence of diplophonia and the glottal conditions in tension imbalance, but not in mass imbalance.     

The role of adjustment of expiratory effort in the control of vocal intensity: clinical assessment of phonatory function.

OBJECTIVE: To determine the role of the adjustment of expiratory effort in the control of vocal intensity. STUDY DESIGN: An intensity-loading test was performed by using the airway interruption method. Three groups of subjects were used: a control group thought to resemble normal vocal fold closure, a group of patients with Reinke's edema thought to represent increased mass at the level of the vocal folds, and a group with vocal fold paralysis that was thought to represent a group with lack of adequate vocal fold closure. RESULTS: In the control group, expiratory lung pressure and airway resistance slightly increased. In the patients with Reinke's edema, expiratory lung pressure, and airway resistance significantly increased. In this group, the voice intensity was controlled by laryngeal adjustment, but a greater expiratory effort was needed because of a greater increase in glottal resistance. In the patients with vocal cord paralysis, airway resistance did not increase even with a high-intensity voice. Vocal intensity was controlled by expiratory effort. CONCLUSIONS: If there is sufficient ability for laryngeal adjustment, vocal intensity is controlled primarily by laryngeal adjustment and by expiratory adjustment in response to increased glottal resistance. However, vocal intensity is controlled by expiratory effort when laryngeal adjustment ability is poor.     

Vocal fold paralysis and progressive cricopharyngeal stenosis reversed by cricopharyngeal myotomy

Three infants with progressive upper esophageal stenosis had bilateral vocal fold paralysis. The patients were apparently normal at birth and without neurologic abnormality. Cricopharyngeal myotomy, followed by serial dilatations, relieved esophageal stenosis and restored the swallowing function. Vocal fold mobility, to the authors’ surprise, also recovered after myotomy in 2 patients. Vocal paralysis persisted in the first patient encountered, although this case was complicated by longstanding tracheostomy. Decannulation in this case was successful at 4 years only after arytenopexy and cricoid interposition grafting. Direct laryngoscopy findings showed weak abductive motion of 1 vocal fold at 14-year follow-up. Loss of vocal function secondary to constriction by a cricopharyngeal band has been previously undocumented. The potential reversibility of both vocal paralysis and esophageal stenosis by surgical cricopharyngeal myotomy is of significant clinical importance.     

Laryngeal framework surgery for the management of aspiration

BACKGROUND: During the past decade, laryngeal framework surgery has become the treatment of choice for the management of adductor paralysis of the vocal fold. The primary impetus for the use of this technique has been on the rehabilitation of voice. The purpose of this study was to ascertain the effectiveness of laryngeal framework surgery, including medialization laryngoplasty with silicone (MLS), with or without arytenoid adduction (AA), on eliminating aspiration, improving diet, and aiding in the subsequent decannulation of individuals with glottic insufficiency secondary to vocal fold palsy. METHODS: A retrospective chart review was performed on all patients initially seen with vocal cord paralysis who were treated with laryngeal framework surgery from June 1992 to April 1996. The study comprised 70 patients, including 31 women and 39 men, with a median age of 57 years. Clinical information was obtained regarding the etiology of the lesion, characteristics of the vocal cord deficit, history of aspiration, the presence of other neurologic deficits or concurrent pulmonary disease, treatment, and outcome. To determine the effectiveness of MLS, with or without AA, we assessed the final outcome regarding the presence and degree of aspiration, diet, history of aspiration pneumonia, and decannulation. RESULTS: Seventy patients underwent 77 MLS (three bilateral, four revisions), and 21 AA. Decreased aspiration was obtained in 96% of our patients. Seventy-five percent of those patients who had required a tracheotomy were decannulated. CONCLUSIONS: These results support the use of laryngeal framework surgery for the effective treatment of aspiration in selected patients initially seen with deficits of the glottic closure secondary to vocal fold paralysis or paresis.     

Biomechanics of combined arytenoid adduction and medialization laryngoplasty in an ex vivo canine model

Arytenoid adduction (AA) and medialization laryngoplasty (ML) are being performed concurrently in patients with unilateral vocal fold paralysis with a large posterior glottal gap. The biomechanical effects of this combined procedure on the larynx have not been studied. An excised canine larynx model was used to study the effects of AA, ML, and combined AA and ML (AA-ML) on vocal fold configuration (length and degree of medialization) and tension. AA-ML lengthens the affected vocal fold relative to the opposite vocal fold, although both were slightly shortened compared with the control state (nonsignificant trends). AA-ML medializes the entire length of the vocal fold more effectively than AA or ML alone. Midmembranous vocal fold tension did not increase with AA-ML. With AA-ML, the vocal process resisted significantly greater lateralizing forces than with the control state or ML. We conclude that in an excised canine model, AA-ML combines the biomechanical properties of AA and ML. The larynx appears to be divided into 2 biomechanical subunits: membranous vocal fold (anterior) and arytenoid cartilage (posterior). When surgical rehabilitation of both laryngeal subunits is required, AA-ML appears to be a better choice than AA or ML alone. (Otolaryngol Head Neck Surg 1998;119:634-42.)