Is it Always Laryngopharyngeal Reflux? How Voice Disorders Can Manifest as LPR

Introduction: Laryngopharyngeal reflux (LPR) manifests with a constellation of common throat symptoms and inconclusive signs on laryngoscopic exam. It is a diagnosis, often made clinically, that can lead to prescriptions of proton pump inhibitors that are unnecessary and potentially harmful. Glottic insufficiency (GI) and the accompanying hyperfunctional laryngeal behaviors can also present with similar, common throat complaints that may or may not include a qualitative change to the voice. Methods: This is a reflection article. It is written to summarize, explain, and support with evidence the opinion of the author on the topic of how symptoms of voice disorders can easily be mistaken for symptoms of LPR. The offered reflection is based on his experience, research and the available literature. Reflection: This article intends to explore the similarities between GI and LPR, how to ultimately differentiate them and how to approach treatment with a broader differential diagnosis. Conclusion: LPR and GI can present with identical, vague throat, and voice symptoms. Empiric medication trials, behavioral interventions and objective laryngovideostroboscopy, impedance-based reflux, and esophageal motility testing may all be needed, sometimes in a trial and error fashion, to correctly diagnose and treat a patient's symptoms.

Introducción: El reflujo laríngeo-faríngeo (LPR, por sus siglas en inglés) se manifiesta con una serie de síntomas comunes en la garganta y signos no concluyentes en el examen larinoscópico. Es un diagnóstico que a menudo se realiza clínicamente y que puede llevar a la prescripción de inhibidores de la bomba de protones que son innecesarios y potencialmente perjudiciales. La insuficiencia glótica (IG) y los comportamientos laríngeos hiperfuncionales que la acompañan también pueden presentar síntomas de garganta comunes similares, que pueden o no incluir un cambio cualitativo en la voz. Métodos: Este es un artículo de reflexión. Está escrito para resumir, explicar y respaldar con evidencia la opinión del autor sobre cómo los síntomas de los trastornos de la voz pueden confundirse fácilmente con los síntomas del LPR. La reflexión ofrecida se basa en su experiencia, investigación y la literatura disponible. Reflexión: Este artículo tiene la intención de explorar las similitudes entre la IG y el LPR, cómo diferenciarlos finalmente y cómo abordar el tratamiento con un diagnóstico diferencial más amplio. Conclusión: El LPR y la IG pueden presentar síntomas idénticos y vagos en la garganta y la voz. Puede ser necesario realizar ensayos de medicación empírica, intervenciones conductuales y pruebas objetivas de laringovideostroboscopia, reflujo basado en impedancia y motilidad esofágica, a veces de manera experimental, para diagnosticar y tratar correctamente los síntomas de un paciente.

The Evaluation of the Short-Term Voice Outcome of Injection Laryngoplasty Using Two Types of Calcium Hydroxylapatite (Radiesse versus Facetem) / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Radiesse® is a widely used calcium hydroxyapatite (CaHA) injection material used for vocal fold injection. Recently, a new CaHA injection material (Facetem ®) which complements the structural disadvantages of Radiesse has been developed and released in the market. The aim of this study is to compare the efficacy and short-term voice outcome of these two CaHA materials. SUBJECTS AND METHOD: A retrospective analysis was performed for 70 patients with unilateral vocal fold paralysis who underwent vocal fold injection using CaHA materials. Acoustic voice analysis, maximal phonation time (MPT), voice handicap index (VHI), and Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scale were evaluated between Radiesse and Facetem injection group. RESULTS: Both groups showed a signifcant improvement of MPT, VHI, and G, B, A scale after injection. The Facetem group showed similar voice improvement as the Radiesse group, where pre- and postoperatively objective and subjective voice evaluation results were compared. CONCLUSION: Our study reveals that there is no significant difference in efficacy and nor any short-term vocal improvement between Radiesse and Facetem. Therefore, the use of Facetem as CaHA injection material could be considered as an alternative material for patients with unilateral vocal cord paralysis.

Efficacy of Calcium Hydroxyapatite in Vocal Fold Augmentation for Unilateral Vocal Fold Paralysis in Asian

BACKGROUND AND OBJECTIVES: This study aimed to evaluate efficacy and complication of injection laryngoplasty using calcium hydroxyapatite (CaHA) for unilateral vocal fold paralysis in Asian. MATERIALS AND METHODS: A prospective study was conducted on the adult patients with unilateral vocal fold paralysis from May 2015 through January 2016. Injection laryngoplasty was performed by one laryngologist. All patients underwent prospective voice evaluation using the subjective and objective comprehensive battery of assessments, before the procedure and after the procedure at 3 months, and 6 months. RESULTS: A total of 7 patients (5 males and 2 females) were included in this study. VHI-10 was significantly decreased after injection laryngoplasty, at postoperative 6 months (p=0.031), while VAS score and MDADI showed no difference. GRBAS scale gradually decreased in 3 months and 6 months follow-up without statistical significance. Acoustic analysis revealed that jitter, shimmer, and noise-to-harmonic ratio continuously decreased from the baseline at 3 months and 6 months, although statistical significance was not attained. In the aerodynamic analysis, maximal phonation time was gradually increased at 3months and 6 months with significant difference (p=0.016, 0.031, respectively). There was no side effect associated with the procedure. CONCLUSION: CaHA can be safely used in Asian patients and the onset of maximal efficacy seems to be slow than other studies with Caucasian patients.

Benefits of Palliative Office-Based Hyaluronic Acid Injection Laryngoplasty in Cancer-Related Unilateral Vocal Cord Paralysis Patients

BACKGROUND AND OBJECTIVES: The effect of palliative injection laryngoplasty in cancer-related unilateral vocal cord paralysis patients on voice and swallowing function is uncertain and there are few previous studies of its suitability, benefits as a palliative treatment option. The purpose of this study is to confirm the objective results of voice and swallowing function after palliative office-based hyaluronic acid injection laryngoplasty in cancer-related unilateral vocal cord paralysis patients. MATERIALS AND METHOD: 36 patients who had unilateral vocal cord paralysis from non-thyroidal, extralaryngeal neoplasms were included in this study. To evaluate the clinical outcome, we analyzed perceptual GRBAS grading, acoustic analysis, aerodynamic study, Electroglottography (EGG), Voice Handicap Index (VHI-30) about voice function and disability rating scale (DRS), gastric tube dependency, aspiration pneumonia about swallowing function and 36-Item Short Form Survey version 2 (SF-36v2) about quality of life. RESULTS: In GRBAS scale, G (p < 0.001), R (p=0.004), B (p=0.001), A (p=0.011), and S (p=0.007) showed significant improvement. Jitter, shimmer, speaking fundamental frequency, maximal phonation time, VHI-30, DRS score, gastric tube dependency, aspiration pneumonia, and SF-36v2 were significantly improved after injection (p=0.016, p=0.011, p=0.045, p=0.005, p < 0.001, p < 0.001 p=0.003, p < 0.001, and p < 0.001 respectively). CONCLUSION: From this study we concluded office-based hyaluronic acid injection can be used as a useful palliative treatment option in cancer-related ill patients with unilateral vocal cord paralysis. Palliative hyaluronic acid injection laryngoplasty avoids the need for tube feeding, thus reducing the risk of aspiration pneumonia. These outcomes are accompanied by significant improvement in voice quality.

Comparison of Voice Outcomes between Medialization Thyroplasty and Arytenoid Adduction with or without Injection Laryngoplasty in Unilateral Vocal Fold Paralysis Patients

BACKGROUND AND OBJECTIVES: In unilateral vocal fold paralysis (VFP), medialization thyroplasty (MT), arytenoid adduction (AA) and injection layrngoplasty (IL) are the most common procedures to correct phonatory problems. There is no consensus that which procedure is superior to the other for correcting the glottal insufficiency. The purpose of this study was to compare the phonatory parameters between MT, AA and AA with IL (AA+IL) in patients with unilateral VFP. MATERIALS AND METHODS: This retrospective study enrolled patients from 2005 to 2016. Total 72 patients (49 male, 23 female, mean age 54.5 years) were classified into three groups ; MT (n=28), AA (n=12), and AA+IL (n=32). GRBAS scales, maximum phonation time (MPT), jitter, shimmer, noise to harmonic ratio (NHR), and voice handicap index (VHI)-10 and VHI-30 were preoperatively and postoperatively collected and compared between the three groups. RESULTS: Age, gender and cause of VFP were not significantly different between the three groups. In MT and AA groups, MPT, VHI, G (overall grade) and B (breathiness) were significantly improved. In AA+IL group, jitter, shimmer, NHR, MPT, VHI, G and B were significantly improved. In analysis of differences (pre-postoperative values), Δ jitter (p < 0.001), Δ shimmer (p=0.031), and Δ NHR (p=0.002) were significantly different and AA+IL group showed the greatest improvement. CONCLUSION: Analysis of voice parameters showed that all the three procedures for patients with unilateral VFP are effective in the improvement of voice ; especially in MPT, VHI-10, G and B scales. Compared to the others, AA+IL provided the better acoustic values including jitter, shimmer and NHR.

Injection Laryngoplasty for The Treatment of Vocal Fold Scar, and Sulcus

BACKGROUND AND OBJECTIVES: The clinical reports for the treatment of vocal fold scar and sulcus vocalis are limited, also there is no best one for the treatment of them. This study is to evaluate the effect of Injection laryngoplasty (IL) for the treatment of vocal fold scar and sulcus vocalis. MATERIALS AND METHODS: from January 2013 to May 2015, the Nineteen patients who were diagnosed as vocal fold scar, sulcus and atrophy, and underwent IL, were engaged in this study. Clinical information and voice parameters were analyzed by retrospective chart review. Pre and post voice parameters were compared. RESULTS: Subgroups of diagnosis were classified into sulcus vocalis for 12 patients, vocal fold scar for 5, and atrophy for 2. IL was performed under local anesthesia through cricothyroid membrane except one patient. Atesense®, Radiessess®, and Rofilan® were used as injected materials in 9, 9, and 1 patients respectively. Maximal phonation time (p=0.0124), dynamic range (p=0.0028), pitch range (p=0.0141), voice handicap index (p=0.028), glottal closure (p=0.0229), and mucosal wave (p=0.0132) had significant improvement for post-IL voice assessment than Pre-IL. While GRBAS, Mean flow rate, Jitter, Shimmer, Harmony to Noise ratio didn't have improvement. CONCLUSION: IL is a feasible option for the treatment of glottis incompetence with normally mobile vocal folds such as sulcus vocalis and vocal fold scar.

Laringoplastía de inyección con ácido hialurónico, experiencia del Hospital Clínico de la Pontificia Universidad Católica de Chile / Laryngoplasty injection with hyaluronic acid, Hospital Clinico de la Pontificia Universidad Catolica de Chile experience

Introducción: El manejo inicial de la parálisis cordal unilateral incluye la observación en espera de la recuperación de la movilidad o la compensación, terapia fonoaudiológica o inyección de medialización temporal para llevar la cuerda a una posición más favorable para el cierre glótico. Este procedimiento puede realizarse en pabellón, o vía percutánea en paciente despierto. Existen varias opciones, siendo el ácido hialurónico (Restylane®) uno de los más usados. Objetivo: Revisar la experiencia pionera en el país en la inyección de medialización de cuerda vocal con ácido hialurónico en el manejo de la parálisis cordal unilateral. Material y método: Estudio retrospectivo, que incluyó a 15 pacientes con insuficiencia glótica a los que se les realizó una inyección percutánea con ácido hialurónico. Se evaluó la calidad de la voz pre y posprocedimiento (VRQOL), tolerancia al procedimiento y complicaciones. Resultados: El 100% de los pacientes mostró cambios significativos en el VRQOL, con un cambio promedio pre y post de 37%. El procedimiento fue bien tolerado en el 93%. No se produjeron incidentes durante la inyección ni tampoco posteriores. Conclusión: La inyección de medialización es un procedimiento bien tolerado, seguro y sencillo, que permite mejoras significativas en la calidad vocal. El ácido hialurónico es seguro y eficaz para la inyección de medialización.

Introduction: Initial treatment options for unilateral vocal fold paralysis include observation for spontaneous return of function or compensation, voice therapy to stimulate recovery of motion or function, or temporary vocal fold injection medialization to improve glottic closure. Temporary injection medialization can be performed under general anesthesia or in the awake-patient setting with local anesthesia. There are different options of temporary injection materials, being hyaluronic acid (Restylane®) one of the most popular. Aim: To review our pioneer experience in Chilewith the use of temporary vocal fold injection with hyaluronic acid in the initial management of unilateral vocal fold paralysis. Material and method: Retrospective study involving 15 patients with glottic insufficiency, who underwent percutaneous vocal fold injection medialization with hyaluronic acid. Pre and post procedure quality of voice (VRQOL), tolerance to the procedure, and complications were evaluated. Results: All patients showed significant changes in VRQOL, with a 37% average improvement. The procedure was well tolerated in 93%. No incidents occurred during injection orlater. Conclusions: The temporary vocal fold injection medialization is a well-tolerated, safe and simple procedure that allows significant short-term improvements in vocal quality of patients. Hyaluronic acid is a safe and effective material for temporary vocal foldinjection medialization.

Manejo de disfonía post cirugía tiroidea con laringoplastía por inyección con ácido hialurónico / Hyaluronic acid in the management of post-thyroidectomy vocal cord paralysis

Introduction: Thyroid surgery rates have tripled over the past 3 decades. Currently, the main postoperative complications of this surgery are vocal fold paralysis because of recurrent laryngeal nerve dysfunction and hypocalcemia. Case report: We report the case of a 58 years old woman who presented with persistent dysphonia post total thyroidectomy. Laryngeal videostroboscopy evidenced unilateral vocal fold paralysis. We performed a percutaneous injection laryngoplasty with hyaluronic acid achieving significant improvement in voice. Conclusions: Percutaneous injection laryngoplasty with hyaluronic acid is a safe and effective procedure in the management of post thyroidectomy vocal cord paralysis.

Introducción: La tasa de cirugía tiroidea se ha triplicado en las últimas 3 décadas. Dentro de sus complicaciones se encuentra la parálisis de cuerda vocal unilateral secundaria a lesión transitoria o permanente del nervio laríngeo recurrente, lo que se presenta clínicamente como disfonía. Caso clínico: Paciente de 58 años, post tiroidectomía total evoluciona con disfonía persistente. Videoestroboscopia evidencia parálisis cuerda vocal izquierda en posición paramediana, con hiato fonatorio longitudinal amplio. Se maneja con laringoplastía por inyección con ácido hialurónico a cuerda vocal paralítica, logrando mejora significativa de voz. En videoestroboscopia de control al 7º día se evidencia cuerda vocal izquierda en línea media, con borde libre recto, sin presencia de hiato al fonar. Conclusiones: La laringoplastía por inyección percutánea con ácido hialurónico es un procedimiento seguro y eficaz para el tratamiento de la disfonía secundaria a parálisis cordal unilateral post cirugía tiroidea.

A Case of Surgical Removal of Hyaluronic Acid Injected in Reinke's Space / 대한이비인후과학회지

Injection laryngoplasty is a simple and noninvasive method for treating unilateral vocal cord paralysis. Lately hyaluronic acid is widely used as injection material, because it is spontaneously resolved after few months and can be injected superficially compared to other materials. However, if hyaluronic acid is injected in the superficial layer of lamina propria (Reinke's space), it can cause inflammation or granuloma, interrupt the vibration of the vocal cord and worsen the quality of voice. We here present a case of granuloma that occurred as a complication of injection laryngoplasty, where simple surgical method was employed to improve voice quality.

Review of Injection Laryngoplasty as Treatment of Voice Disorders / 이화의대지

In the past decade, vocal fold injection (VFI) has re-emerged as a valuable treatment modality for a variety of laryngeal disorders. It offers many advantages for the treatment of glottal insufficiency. It can avoid surgical scar and is easily performed with local anesthesia. In this article, we describe the indication of injection laryngoplasty, variable injection materials and discuss about vocal fold injection approaches.

Comparative Analysis of Efficiency of Injection Laryngoplasty Technique for with or without Neck Treatment Patients: A Transcartilaginous Approach Versus the Cricothyroid Approach

OBJECTIVES: These days, the main injection laryngoplasty technique is cricothyroid (CT) approach. However, patients who have previously undergone other neck treatments, such as thyroidectomy or neck dissection have distorted anatomical landmark makes this approach more difficult. The aim of this study is to determined the efficiency of transcartilaginous (TC) approah as compared with CT approach for unilateral vocal fold paralysis patients, especially for previously neck treated patients. METHODS: From March 2005 to February 2008, 137 consecutive injection laryngoplasties were performed in patients with unilateral glottic insufficiency. Percutaneous injection was performed under local anesthesia into the vocalis muscle, using disposable 25 G 4 cm long needles through the cricothyroid membrane or directly through the thyroid cartilage. Of the 137 patients, 124 completed acoustic, perceptual, stroboscopic, and subjective evaluations prior to the injection and at 3 months after the injection. RESULTS: In the 124 patients, the CT and TC approaches were used in 94 and 30 patients, respectively. Acoustic and perceptual parameters (GRBAS, MPT, jitter, shimmer), voice handicap index, and grades of mucosal waves and glottic closure were significantly improved after the injection in both the CT and TC groups (P<0.05). Only two patients (6.6%) had penetration difficulties, because of ossification of the thyroid cartilage. The overall success rates of the CT and TC approaches were 86.2%, 93.3%, respectively. However, the success rate of the TC approach in patients who had previously undergone neck treatments was significantly higher than that of the CT approach (100% vs. 65% P<0.05). CONCLUSION: Based on the preliminary results of this trial, injection laryngoplasty using a TC approach was an effective alternative to the CT approach, especially in patients who had previously undergone neck surgeries.

Role of Temporary Injection Laryngoplasty in Acute Unilateral Vocal Fold Paralysis with Aspiration / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: We evaluated the role of temporary injection laryngoplasty in patients with unilateral vocal fold paralysis (UVFP) after cardiothoracic surgeries. SUBJECTS AND METHOD: Taking the introduction of injection laryngoplasty as a milestone, we divided patients into those who underwent cardiothoracic surgery with UVFP during the years 2001-2004, before the introduction of injection laryngoplasty as pre-injection group (n=83) and those who underwent after the introduction during the years 2000-2007 as post-injection group (n=103). Of the post injection group, patients who received injection laryngoplasty postoperatively before being discharged were defined as injection group (n=37). Patients were also divided into non-esophageal surgery group and esophageal surgery group. Clinical outcomes including the length of hospital stay and oral feeding initiation time were compared between the pre-injection group and the injection group within the same operation group. The degrees of aspiration were classified into 4 grades. RESULTS: In the non-esophageal surgery group, the injection group with aspiration grade III had shorter hospital stay and oral feeding initiation time after extubation compared to the pre-injection group with grade III aspiration (p=0.042). However, in the esophageal surgery group, there was no statistical difference between the pre-injection and injection groups. CONCLUSION: Temporary injection laryngoplasty can reduce the hospital stay and enhance oral feeding initiation in patients with aspiration due to UVFP after non-esophageal cardiothoracic surgeries.

Lateral vocal fold injection of autogenous fat for vocal fold insufficiency / 中国耳鼻咽喉头颈外科

OBJECTIVE To study the efficacyof the lateral vocal fold injection of autogenous fat for vocal fold insufficiency. METHODS Twenty nine patients with vocal fold insufficiency were treated in our department with fat injection. Deep lateral vocal fold injection was performed through direct laryngoscope under general anesthesia. Fat was injected into the lateral aspect of the vocal fold (paraglottic space) using a special high pressure Brunning injector. The perceptual acoustic,phonatory function,and video laryngostroboscopy were evaluated before and after operation. RESULTS All the patients were followed up for 10 to 18 months. There were 24 patients with excellent results,2 patients with improvement, and 3 patients with no improvement. Phonatory function showed significant improvement(P

Histology and Stroboscopic Findings after Injection of Artecoll(R) and Restylane(R) into Paralyzed Canine Vocal Fold: in vivo Canine Study / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The aims of this study are to introduce Artecoll and Restaylane, that have been available for facial augmentation, as new materials for injection laryngoplasty, to investigate the mucosal wave of true vocal folds after the injection of these two materials into the true vocal fold, and to assess its biocompatibility and durability. SUBJECTS AND METHOD: After complete paralysisof the right recurrent laryngeal nerve of 6 Beagle dogs, the dogs were divided into the Artecoll injection group and the Restylane injection group, and Artecoll or Restylane was injected into vocalis muscle and vocal ligament. The recurrent laryngeal nerve of the opposite side was stimulated, the posterior commissure was sutured, and the mucosal wave of true vocal folds was examined by stroboscopy in in vivo canine study 1, 3, and 6 months after the injection. And, histopathological change of the injected materials after total laryngectomy was examined by hematoxylin and eosin (H & E) staining and masson trichrome staining. RESULTS: In both the Artecoll injection and the Restylane injection groups, the mucosal wave of true vocal folds was detected by stroboscopic examination until 6 months after the injection, and the difference of the mucosal wave of true vocal folds between these two groups was difficult to detect. Histological studies revealed that the injected materials remained in the vocal ligament and vocalis muscle and theses two materials were resorbed with time, Artecoll showing less resorption. These two materials were biocompatible and, particularly, Restylane showed less foreign body reaction. CONCLUSION: Since both Artecoll and Restylane are biocompatible and durable, they areconsidered as the suitable material for injection larygoplasty, and additional long-term studies are required.