Evidence of return of function in patients with vocal fold paresis

Unilateral vocal fold paresis (UVFP) patients were examined over time for achievement of partial or full functional return or no functional return in the extent of arytenoid movement, clarity of laryngeal articulation, maximum phonation time (MPT), and flow. Effects of treatment type and initial laryngeal electromyography (EMG) results were examined. A retrospective chart review was completed for patients a year or less after onset evaluated between April 1999 and December 2005 and treated between 2 and 20 months after onset. Twenty-one individuals were evaluated (11 males, age: 34-89 years) and subsequently treated (10 by injection and 11 by thyroplasty). Evidence of full functional return was found for the extent of arytenoid movement in 25% of individuals, for clarity of laryngeal articulation in 71%, for MPT in 58%, and for flow in 50%. No evidence of functional return was found for the extent of arytenoid movement in 33% of the individuals, for clarity of laryngeal articulation in 8%, for MPT in 32%, and for flow in 22%. All pairs of outcome measures showed poor agreement in the level to which they functionally returned. More individuals with signs of reinnervation demonstrated MPTs with full functional return than expected. Patients with UVFP, even after treatment and at least 12 months postinjury did not demonstrate full functional return for all measures. Differences across measures in the percentage of individuals demonstrating each level of function and the lack of agreement of function level between measures within individuals suggest the need to use multiple outcome measures. © 2010 The Voice Foundation

Using laryngeal electromyography to differentiate presbylarynges from paresis

Purpose: Differential diagnosis of patients over 64 years of age reporting hoarseness is challenging. Laryngeal electromyography (LEMG) was used to determine the status of the recurrent and superior laryngeal nerves. The authors hypothesized that individuals with hoarseness but normal LEMG would have measures similar to those of patients from previous studies with presbylarynges and significantly different from those of patients with abnormal LEMG. Method: A retrospective chart review of acoustic, aerodynamic, endoscopic, and self-rating measures was completed for 52 individuals over 64 years of age reporting moderate to severe hoarseness. Results: Individuals with normal LEMG had measures similar to those of patients from previous studies diagnosed with presbylarynges. The group with LEMG abnormalities was subcategorized by specific nerve(s) affected. Significant differences were found for measures between presbylarynges and unilateral but not bilateral paresis groups. Several endoscopic findings were observed more often than expected in the presbylarynges group. Using electromyography as a gold standard, the presence of any impairment in arytenoid movement had the most sensitivity (77%) in making the diagnosis of paresis, and the absence of any impairment had the most specificity (67%) in making the diagnosis of presbylarynges. Conclusion: LEMG may be useful in differentially diagnosing hoarseness in older patients, especially to distinguish between bilateral paresis and presbylarynges. © American Speech-Language-Hearing Association

Laryngeal abscess after injection laryngoplasty with micronized AlloDerm

Objective: Patients with unilateral vocal cord paralysis usually present with dysphonia and occasionally with swallowing problems. Operative management includes thyroplasty type I, injection laryngoplasty, arytenoid adduction, and reianervation. Recent publications have documented the safety of micronized AlloDerm (Cymetra, LifeCell Corporation, Branchburg, NJ) for injection laryngoplasty, but we report the first documented case of a laryngeal abscess after injection laryngoplasty with Cymetra. Study Design: Single case report of a laryngeal abscess after injection laryngoplasty with Cymetra. Methods: The patient\u27s clinical course is presented and discussed, and the pertinent literature is reviewed. Results: Prompt hospital admission with intravenous antibiotics and steroids resolved this airway emergency. Follow-up visits showed a significantly unproved postoperative voice with an intact airway. Conclusion: A review of the literature reveals that this case of a laryngeal abscess after injection laryngoplasty with Cymetra is the first of its kind. Studies have shown that the use of AlloDerm in the head and neck region is safe, but otolaryngologists need to be cognizant of potential complications when working with this material

Perceived vocal fatigue and effort in relation to laryngeal functional measures in paresis patients

Objectives/Hypothesis To determine if differences in objective measures of laryngeal function can meaningfully explain different levels of self-perceptions of effort or fatigue in patients with vocal fold paresis. Study Design A retrospective chart review of 72 patients with vocal fold paresis diagnosed using laryngeal electromyography, who had either been observed (n=21), treated only by injection (n=24), or treated only by surgery (n=27). Methods Before and after treatment/observation, patients\u27 subjective ratings of severity of vocal effort and fatigue were assessed using the Glottal Function Index. Laryngeal function was assessed using maximum phonation time and translaryngeal flow. Results None of the variables demonstrated a significant linear change across time. Post hoc Tukey analyses following analysis of variance (ANOVA) found significant differences in flow among three groups, those rating symptoms of effort as no problem, moderate problem, or severe problem. Post hoc Tukey analyses following ANOVA found significant differences in the amount that flow changed among three groups, those demonstrating no difference, minor differences, or major differences in ratings of effort before and after treatment. Conclusions Changes in reported symptom severity of effort were related to changes in translaryngeal midvowel flow that were not explained by passage of time. Level of Evidence 4. Laryngoscope, 124:1631-1637, 2014 © 2013 The American Laryngological, Rhinological and Otological Society, Inc

Long-Term Voice Change in Presbylarynges Patients With and Without Intervention

PURPOSE: To explore long-term patient experience of treated and untreated presbylarynges patients two or more years after their previous clinic visit by their responses to a probe about the changes in voice (better, stable, or worse) and standardized rating scales either by phone or from clinic records. Congruences of rating differences between visits and probe responses were assessed. METHODS: Thirty-seven participated prospectively and seven retrospectively. Better, stable, or worse probe responses and treatment follow-through were obtained. Self-rating scales, completed verbally or obtained from charts, were compared to the previous visit so differences between visits could be converted to be congruent with probe responses. RESULTS: After a mean of 4.6 years, 44% (63% untreated) reported stable, 36% (38% untreated) worse, and 20% (89% untreated) better. Significantly greater proportions of untreated reported better/stable probe responses while treated reported worse (χ2; P = 0.038). Significantly better means for all ratings were found at follow-up for those with better probe responses, but mean ratings were not significantly worse for those with worse probe response. No significant congruences of rating differences between visits and probe responses were found. In untreated reporting stable probe response, a significantly greater proportion of those with previous clinic ratings within normal limits (WNL) maintained ratings WNL at follow-up (z-statistic; P = 0.0007). CONCLUSIONS: Ratings WNL at the initial evaluation, especially voice-related quality of life and effort, were found to still be WNL after several years. Little congruence was found between rating differences and probe responses, especially for worse, suggesting need for developing more sensitive rating scales

Endoscopic lysis of anterior glottic webs and silicone keel placement

Objectives: Acquired anterior glottic webs occur most commonly after endoscopic resection of laryngeal papilloma involving the anterior vocal folds. Treatment of anterior glottic webs has included a tracheotomy with laryngofissure and placement of a laryngeal stent or keel. We have used an endoscopic technique of web lysis and placement of a laryngeal keel without tracheotomy over the past 7 years. Methods: A retrospective chart review was conducted of all cases of endoscopic web lysis and keel placement performed by the senior author (S.A.B.). Results: Over the past 7 years, 10 patients underwent the procedure, with a mean follow-up of 18 months. The length of the anterior web was up to two thirds of the membranous vocal fold. Outcomes analysis revealed a recurrence in 1 patient and 2 minor complications necessitating treatment. Conclusions: Endoscopic web lysis and keel placement offers superior results with less morbidity compared to open techniques. © 2007 Annals Publishing Company. All rights reserved

Primary care perceptions of otolaryngology

Objective: To identify diseases of the head and neck for which primary care physicians may underappreciate the role of the otolaryngologist. Study Design: Cross-sectional analysis. Setting: With increasing subspecialization in the world of medicine, there is the potential for confusion about the scope of practice for different specialties by primary care physicians. These clinicians are often faced with patients who have disease processes in which otolaryngologist are trained but may end up referring patients to other specialists. Subjects and Methods: A brief, web-based survey was administered via e-mail to resident physicians of family medicine, pediatrics, and internal medicine programs in the United States. The survey asked responders which specialist they believed was an expert for particular clinical entities: allergies, oral cancer, restoring a youthful face, sleep apnea, thyroid surgery, and tracheostomy. Respondents could choose from a dermatologist, general surgeon, ophthalmologist, oral maxillofacial surgeon, orthopedic surgeon, otolaryngologist, and plastic surgeon. The responder was able to choose more than one specialist for each question. Results: A total of 1064 completed surveys were analyzed. The percentage of primary care residents who picked otolaryngologists as experts was 13.8 percent for allergies, 73.6 percent for oral cancer, 2.7 percent for restoring a youthful face, 32.4 percent for sleep apnea, 47.2 percent for thyroid surgery, and 72.5 percent for tracheostomy. Conclusion: This study demonstrates that many primary care residents are not aware of the scope of expertise that an otolaryngologist may offer. Increased exposure to otolaryngology during primary care residency training may increase understanding of the specialty among primary care physicians. © 2010 American Academy of Otolaryngology/Head and Neck Surgery Foundation. All rights reserved

Treatment effectiveness for aging changes in the larynx

© 2017 The American Laryngological, Rhinological and Otological Society, Inc. Objectives: To compare the effectiveness of injection augmentation and bilateral thyroplasty surgery in managing age-related changes of the larynx. Study Design: Retrospective chart review of patients treated with bilateral thyroplasty and/or injection augmentation. Methods: We evaluated 22 patients before and after treatment using: 1) normalized glottal gap area and normalized true vocal fold width from endoscopic images; 2) patient self-rating questionnaires; and 3) acoustic and aerodynamic measures. Results: Thyroplasty surgery resulted in 38% of patients demonstrating less bowing compared to 33% after injection, and 63% demonstrated less supraglottic activity compared to 43% after injection (P = 0.09). Change in mean Voice-Related Quality of Life (V-RQOL) scores was 25.5 after thyroplasty compared to −16.4 after injection (P \u3c 0.05). Those exhibiting a greater than 20 change in V-RQOL after treatment were significantly more likely to report swallowing symptoms pretreatment. Conclusion: Patients postinjection did not rate themselves on any questionnaires as significantly better compared to pretreatment, whereas patients post-thyroplasty rated themselves as significantly improved on all questionnaires. Patients post-thyroplasty rated their voices as significantly closer to their best voice than patients postinjection. Likewise, 64% of patients who had thyroplasty surgery reported a significant treatment effect compared to 33% for injection augmentation. Level of Evidence: 4. Laryngoscope, 127:2572–2577, 2017

Treatment effectiveness for aging changes in the larynx

© 2017 The American Laryngological, Rhinological and Otological Society, Inc. Objectives: To compare the effectiveness of injection augmentation and bilateral thyroplasty surgery in managing age-related changes of the larynx. Study Design: Retrospective chart review of patients treated with bilateral thyroplasty and/or injection augmentation. Methods: We evaluated 22 patients before and after treatment using: 1) normalized glottal gap area and normalized true vocal fold width from endoscopic images; 2) patient self-rating questionnaires; and 3) acoustic and aerodynamic measures. Results: Thyroplasty surgery resulted in 38% of patients demonstrating less bowing compared to 33% after injection, and 63% demonstrated less supraglottic activity compared to 43% after injection (P = 0.09). Change in mean Voice-Related Quality of Life (V-RQOL) scores was 25.5 after thyroplasty compared to −16.4 after injection (P \u3c 0.05). Those exhibiting a greater than 20 change in V-RQOL after treatment were significantly more likely to report swallowing symptoms pretreatment. Conclusion: Patients postinjection did not rate themselves on any questionnaires as significantly better compared to pretreatment, whereas patients post-thyroplasty rated themselves as significantly improved on all questionnaires. Patients post-thyroplasty rated their voices as significantly closer to their best voice than patients postinjection. Likewise, 64% of patients who had thyroplasty surgery reported a significant treatment effect compared to 33% for injection augmentation. Level of Evidence: 4. Laryngoscope, 127:2572–2577, 2017

Foreign body reaction to calcium hydroxylapatite vocal fold augmentation

We report a case of inflammation with foreign body cell reaction following injection of the true vocal folds (TVFs) with Radiesse (Bioform Inc, San Mateo, Calif), a synthetic calcium hydroxylapatite (CaHA) material. The patient underwent injection laryngoplasty for a 10-year history of persistent hoarseness and documented bilateral vocal fold paresis. Initial postoperative examination revealed overaugmentation with migration of the material. The material was removed in 2 successive procedures. Results of histological examination revealed the presence of chronic inflammation and foreign body giant cells (FBGCs). This is, to our knowledge, the first published case of an apparent FBGC reaction to vocal fold augmentation with Radiesse and leads us to conclude that rare CaHA rejection reactions can occur in human subjects. ©2006 American Medical Association. All rights reserved