In-office Laryngeal Procedures: a Modern Perspective for Vocal Fold Interventions

Introduction: The purpose of this article is to discuss in-office laryngeal procedures as an alternative to surgical intervention under general anesthesia. In-office procedures have become more common due to technological advancements. As a result, these approaches are less invasive and more patient-friendly, with increased pain tolerance and reduced procedure time and cost. Methods: We conducted a thematic analysis of published reports regarding the best known and performed in-office laryngeal interventions. Three questions guided our analysis: What laryngological procedures can be performed in the office setting? What are the advantages of in-office laryngology procedures compared to operating room surgical procedures? Why aren't more in-office procedures performed in some Latin American countries? Discussion: Despite being performed more frequently, there is still controversy whether in-office procedures should be performed as often due to the risk of complications. Furthermore, procedures that are done in the office setting are more popular in some countries than in others, even though their benefit has been well demonstrated. This article describes various in-office procedures, including biopsy, vocal fold injections, and laser surgery. We also discuss what factors might contribute to having office-procedures being performed more frequently in some countries than others. Conclusion: Awake interventions offer numerous benefits, including shorter procedure time, reduced costs, and lower patient morbidity. These advantages have significantly transformed the treatment of laryngeal diseases in modern laryngology practice in a global manner.

Introducción: El propósito de este artículo es discutir los procedimientos laríngeos en el consultorio como una alternativa a la intervención quirúrgica bajo anestesia general. Los procedimientos en consultorio se han vuelto más comunes debido a los avances tecnológicos. Como resultado, estos enfoques son menos invasivos y más amigables para el paciente, con mayor tolerancia al dolor y reducción del tiempo y costo del procedimiento. Métodos: Realizamos un análisis temático de los informes publicados sobre las intervenciones laríngeas más conocidas y realizadas. Tres preguntas guiaron nuestro análisis: ¿Qué procedimientos laringológicos se pueden realizar en el consultorio y cuales sin los más frecuentes?, ¿cuáles son las ventajas de los procedimientos laringológicos fuera del quirófano frente a los que se realizan bajo anestesia general?, ¿por qué no se realizan más procedimientos laringológicos en el consultorio en la mayoría de los países en Latinoamérica? Discusión: A pesar de que se realizan con mayor frecuencia, aún existe controversia sobre si los procedimientos en consultorio deben realizarse con tanta frecuencia debido al riesgo de complicaciones. Además, los procedimientos que se realizan en el consultorio son más populares en algunos países que en otros, aunque sus beneficios han sido bien demostrados. Este artículo describe varios procedimientos en el consultorio, incluida la biopsia, las inyecciones de cuerdas vocales y la cirugía con láser. También se discutieron los factores que podrían contribuir a que los procedimientos en el consultorio se realicen con más frecuencia en algunos países que en otros. Conclusión: Las intervenciones con pacientes despiertos ofrecen numerosos beneficios, incluido un tiempo de procedimiento más corto, costos reducidos y una menor morbilidad para el paciente. Estas ventajas han transformado significativamente el tratamiento de las enfermedades laríngeas en la práctica de la laringología moderna a nivel mundial.

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.

Split cricoideo anterior posterior: una novedosa técnica para evitar la traqueotomía en parálisis cordal bilateral en pacientes pediátricos / Posterior anterior cricoid split: a cutting-edge technique to avoid tracheostomy in bilateral cordal paralysis in pediatric patients

Introducción: La parálisis cordal bilateral en aducción es la segunda causa de estridor congénito y genera una grave obstrucción de la vía aérea, debutando con estridor. La traqueotomía ha sido durante mucho tiempo el gold estándar para el tratamiento de esta afección, no exenta de complicaciones. Existen procedimientos que intentan evitar la traqueotomía, como el split cricoideo anterior posterior endoscópico (SCAPE). Objetivo: Presentar experiencia con SCAPE en pacientes pediátricos como tratamiento alternativo de parálisis cordal bilateral en aducción. Material y Método: Análisis retrospectivo de los resultados quirúrgicos obtenidos en pacientes con parálisis cordal bilateral en aducción tratados con SCAPE entre enero de 2016 y diciembre de 2019 en el Hospital Guillermo Grant Benavente de Concepción, Chile. Resultados: Siete pacientes se sometieron a SCAPE. Todos los pacientes presentaban insuficiencia respiratoria severa, cinco requirieron asistencia ventilatoria mecánica. Seis pacientes tenían el diagnóstico de parálisis cordal bilateral (PCB) congénita y uno PCB secundaria a tumor de tronco cerebral. Cuatro pacientes presentaron comorbilidad de la vía aérea: dos pacientes presentaron estenosis subglótica grado I y dos pacientes presentaron laringomalacia que requirió manejo quirúrgico. Los días promedio de intubación fueron once días. Ningún paciente requirió soporte ventilatorio postoperatorio, sólo un paciente recibió oxigenoterapia nocturna debido a hipoventilación secundaria a lesión de tronco. Ningún paciente ha presentado descompensación respiratoria grave. Un 40% ha recuperado movilidad cordal bilateral. Conclusión: Split cricoideo anteroposterior endoscópico es una alternativa eficaz para tratar el PCB en pacientes pediátricos. Nuestro estudio evidencia que es una alternativa a la traqueotomía, con excelentes resultados y menor morbimortalidad.

Introduction: Bilateral vocal fold paralysis in adduction is the second cause of congenital stridor and generates a serious obstruction of the airway. Tracheostomy has long been the gold standard for the treatment of this condition, but it has inherent complications. There are procedures that try to avoid tracheotomy, such as the endoscopic anterior posterior cricoid split (EAPCS). Aim: Present our experience with EAPCS in pediatric patients as a treatment for bilateral vocal fold paralysis in adduction. Material and Method: Retrospective analysis of the surgical results obtained in patients with bilateral vocal cord paralysis in adduction treated with EAPCS between January 2016 and December 2019 at Guillermo Grant Benavente Hospital in Concepción, Chile. Results: Seven patients underwent EAPCS. All patients had severe respiratory failure, five required mechanical ventilation assistance. Six patients were diagnosed with congenital bilateral cord palsy (BCP) and one BCP secondary to a brainstem tumor. Four patients had airway comorbidity: two patients had grade I subglottic stenosis and two patients had laryngomalacia that required surgical management. The average days of intubation were eleven days. No patient required post op invasive/non-invasive ventilation, only one patient received nocturnal oxygen therapy due to hypoventilation secondary to trunk injury. None of the patients has presented severe respiratory decompensation. Forty percent have recovered bilateral chordal mobility. Conclusion: SCAPE is a cutting-edge and effective alternative to treat PCB in pediatric patients. Our study shows that it is an alternative to tracheotomy, with excellent results and lower morbidity and mortality.

Outcomes of endoscopic percutaneous suture lateralization for neonatal and infantal bilateral vocal ford paralysis

Abstract Objective: Bilateral Vocal Fold Paralysis (BVFP) is a rare but significant resource of respiratory distress in neonates and infants. The objective of this study was to evaluate the efficacy and functional outcomes of Endoscopic Percutaneous Suture Lateralization (EPSL) for the treatment of BVFP in neonates and infants. Methods: A case series study of nine patients undergoing EPSL for BVFP between January 2019 and June 2021 was conducted. All patients were candidates for tracheostomy prior to EPSL. Demographic features including gender, age at diagnosis and surgery, main symptoms, airway comorbidities, airway support, and etiology were collected preoperatively. Patients were evaluated for breathing, swallowing and phonation postoperatively. Surgical success was defined as the ability to avoid tracheostomy. Functional Endoscopic Evaluation of Swallowing (FEES) was conducted to identify aspiration. Voice evaluation was based on clinical observation. Results: Nine patients underwent ten EPSL procedures (one in the left vocal fold, and nine in the right vocal fold). Eight patients (8/9) were able to successfully avoid tracheostomy and feed orally without aspiration after the procedure. One patient experienced clinical improvement in respiratory support requirements and underwent laparoscopic nissen and gastrostomy tube placement. At the last follow-up, two patients regained normal voice, two patients had mild dysphonia, and five patients had moderate dysphonia. Five patients showed partial return of the contralateral vocal fold function. Conclusion: EPSL is an effective and safe treatment for neonatal and infantal BVFP, which enables patients free from tracheostomy without significant impact on swallowing function or phonation. Level of evidence: Level 4.

Comparação entre a frequência fundamental acústica da voz e a frequência de vibração das pregas vocais analisada pela videoquimografia digital / Comparison between the acoustic fundamental frequency of the voice and the vibration frequency of the vocal folds analyzed by digital kymography

RESUMO Objetivo Comparar a frequência da variação da abertura das pregas vocais, analisada pela videoquimografia digital, com a frequência fundamental da voz, obtida através da análise acústica, em indivíduos sem alteração laríngea. Método Trata-se de um estudo observacional analítico transversal. Participaram 48 mulheres e 38 homens, de 18 a 55 anos. A avaliação foi composta por análise acústica da voz, obtida pela emissão habitual da vogal /a/ durante 3 segundos, e os dias da semana, e pela videoquimografia digital (DKG), obtida pela emissão habitual das vogais /i/ e /ɛ/. As medidas analisadas foram a frequência fundamental acústica (f0), extraída pelo programa Computerized Speech Lab (CSL), e a frequência dominante da variação de abertura da prega vocal direita (D-freq) e esquerda (E-freq), obtidas através do programa de processamento de imagens KIPS. A montagem dos quimogramas constou na demarcação manual da região, compostas por linhas verticais que delimitaram largura da prega vocal e linhas horizontais que marcaram os terços posterior, médio e anterior da rima glótica. Na análise estatística, o teste Anderson-Darling foi utilizado para verificar a normalidade da amostra. Os testes ANOVA e Tukey foram realizados para a comparação das medidas entre os grupos. Para a comparação da idade entre os grupos, foi utilizado o teste Mann-Whitney. Resultados Não existem diferenças entre os valores da medida de frequência analisada pela videoquimografia digital, com a frequência fundamental acústica, em indivíduos sem alteração laríngea. Conclusão Os valores da frequência dominante da variação de abertura das pregas vocais, avaliada pela videoquimografia digital, e a frequência fundamental acústica da voz são similares, permitindo uma comparação entre estas medidas na avaliação multidimensional da voz, em indivíduos sem alteração laríngea.

ABSTRACT Purpose To compare the frequency of vocal fold opening variation, analyzed by digital kymography, with the fundamental voice frequency obtained by acoustic analysis, in individuals without laryngeal alteration. Methods Observational analytical cross-sectional study. The participants were forty-eight women and 38 men from 18 to 55 years of age. The evaluation was made by voice acoustic analysis, by the habitual emission of the vowel /a/ for 3 seconds, and days of the week, and digital kymography (DKG), by the habitual emission of the vowels /i/ and /ɛ/. The measurements analyzed were acoustic fundamental frequency (f0), extracted by the Computerized Speech Lab (CSL) program, and dominant frequency of the variation of right (R-freq) and left (L-freq) vocal fold opening, obtained through the KIPS image processing program. The mounting of the kymograms consisted in the manual demarcation of the region by vertical lines delimiting width and horizontal lines separating the posterior, middle and anterior thirds of the Rima glottidis. In the statistical analysis, the Anderson-Darling test was used to verify the normality of the sample. The ANOVA and Tukey tests were performed for the comparison of measurements between the groups. For the comparison of age between the groups, the Mann-Whitney test was used. Results There are no differences between the values of the frequency measurement analyzed by digital kymography, with the acoustic fundamental frequency, in individuals without laryngeal alteration. Conclusion The values of the dominant frequency of the vocal folds opening variation, as assessed by digital kymography, and the acoustic fundamental frequency of the voice are similar, allowing comparison between these measurements in the multidimensional evaluation of the voice, in individuals without laryngeal alteration.

Regenerative potential of basic fibroblast growth factor contained in biodegradable gelatin hydrogel microspheres applied following vocal fold injury: Early effect on tissue repair in a rabbit model / Potencial regenerativo do fator básico de crescimento de fibroblastos contido em microesferas biodegradáveis de hidrogel de gelatina aplicadas após lesão de prega vocal: efeito inicial no reparo tecidual em modelo de coelho

Abstract Introduction Postoperative dysphonia is mostly caused by vocal fold scarring, and careful management of vocal fold surgery has been reported to reduce the risk of scar formation. However, depending on the vocal fold injury, treatment of postoperative dysphonia can be challenging. Objective The goal of the current study was to develop a novel prophylactic regenerative approach for the treatment of injured vocal folds after surgery, using biodegradable gelatin hydrogel microspheres as a drug delivery system for basic fibroblast growth factor. Methods Videoendoscopic laryngeal surgery was performed to create vocal fold injury in 14 rabbits. Immediately following this procedure, biodegradable gelatin hydrogel microspheres with basic fibroblast growth factor were injected in the vocal fold. Two weeks after injection, larynges were excised for evaluation of vocal fold histology and mucosal movement. Results The presence of poor vibratory function was confirmed in the injured vocal folds. Histology and digital image analysis demonstrated that the injured vocal folds injected with gelatin hydrogel microspheres with basic fibroblast growth factor showed less scar formation, compared to the injured vocal folds injected with gelatin hydrogel microspheres only, or those without any injection. Conclusion A prophylactic injection of basic fibroblast growth factor -containing biodegradable gelatin hydrogel microspheres demonstrates a regenerative potential for injured vocal folds in a rabbit model.

Resumo Introdução A disfonia pós-operatória é causada principalmente por cicatrizes nas pregas vocais. Tem sido relatado que o manejo cuidadoso da cirurgia das pregas vocais reduz o risco de formação de cicatriz. No entanto, a depender da lesão da prega vocal, o tratamento da disfonia pós-operatória pode ser desafiador. Objetivo Desenvolver uma nova abordagem regenerativa profilática para o tratamento de pregas vocais lesionadas após a cirurgia, com microesferas biodegradáveis de hidrogel de gelatina como sistema de administração de medicamentos para o Fator Básico de Crescimento de Fibroblastos (bFGF). Método A cirurgia laríngea videoendoscópica foi feita para criar lesão nas pregas vocais em 14 coelhos. Imediatamente após esse procedimento, microesferas biodegradáveis de hidrogel de gelatina com bFGF foram injetadas na prega vocal. Duas semanas após a injeção, as laringes foram excisadas para avaliação da histologia das pregas vocais e do movimento da mucosa. Resultados A presença de função vibratória deficiente foi confirmada nas pregas vocais lesionadas. A histologia e a análise de imagem digital demonstraram que as pregas vocais lesionadas injetadas com microesferas de hidrogel de gelatina com bFGF apresentaram menor formação de cicatriz, em comparação com as pregas vocais lesionadas injetadas apenas com microesferas de hidrogel de gelatina ou aquelas sem injeção. Conclusão Uma injeção profilática de microesferas biodegradáveis de hidrogel de gelatina com bFGF demonstra um potencial regenerativo para pregas vocais lesionadas em um modelo de coelho.

Effect of Voice Training on Vocal Function for Patients with Early Vocal Fold Polyps / 中国康复理论与实践

Objective:To investigate the clinical effect of voice training on the vocal function of patients with early vocal fold polyps. Methods:From May, 2016 to May, 2018, 80 patients with unilateral wide-based vocal fold polyps were randomly divided into control group (n = 40) and experimental group (n = 40). Both groups underwent voice hygiene education, and the experimental group accepted voice training, 40 minutes a week for twelve weeks in addition. They were evaluated with fiber laryngoscope, voice handicap index (VHI) and the computer phonatory detection before and after training. Results:Five in the control group and seven in the experimental group were dropped out. After training, the cure rate and the improvement rate of vocal fold polyps were significantly higher in the experimental group than in the control group (χ2 = 24.608, P < 0.001). The scores of VHI significantly improved in the experimental group (t/Z > 11.701, P < 0.05), and were better than those in the control group (t/Z > 7.027, P < 0.001). The scores of jitter, shimmer, and maximum phonation time improved (|t/Z| >5.012, P < 0.001) after training in the experimental group, and were better than those in the control group (t/Z > 4.596, P < 0.001). Conclusion:Voice training could improve the vocal function of patients with early vocal fold polyps, reduce hoarseness, and improve the voice quality.

Clinical outcomes of vocal fold immobility after tracheal intubation / 北京大学学报(医学版)

OBJECTIVE@#To assess the incidence of postoperative vocal cord immobility in patients following endotracheal intubation underwent general anesthesia.@*METHODS@#We retrospectively enrolled patients who underwent surgical procedures with endotracheal intubation under general anesthesia from January 2014 to December 2018 in Peking University First Hospital. Demographic and treatment data were obtained for patients with hoarseness and vocal cord fixation. The incidence of postoperative hoarseness and vocal cord fixation were presented and clinical outcomes were further analyzed.@*RESULTS@#A total of 85 998 patients following tracheal intubation and general anesthesia were enrolled in this study. Hoarseness was observed in 222 (0.26%) patients postoperatively. Sixteen patients (73%) were accomplished with symptoms of choking on water, dysphonia and sore throat. Twenty-nine patients with persistent hoarseness on the third postoperative day needed further treatment by otolaryngologists. Among them, seven patients had pharyngolaryngitis and twenty-two patients (0.026%) were demonstrated postoperative vocal cord immobility. There were seventeen patients (77%) with left-side vocal cord fixation and five patients (23%) with right-side vocal cord fixation. Nine patients were identified with arytenoid dislocation. Seven patients had left vocal cord fixation and two patients had right-side vocal cord fixation. Seven patients were intubated under the guidance of visual laryngoscope. One patient was confirmed difficult airway and intubated with light wand. One patient was inserted with laryngeal mask airway. One patient was suspected to have hoarseness caused by gastric tube before anesthesia. One patient showed simultaneously left recurrent laryngeal nerve abnormality on laryngeal electromyography result. The symptom of hoarseness ranged between 6 and 31 days. Three patients underwent closed reduction under local anesthesia and one patient demonstrated spontaneous recovery. Among the remaining thirteen patients with vocal cord immobility, two patients were demonstrated vocal cord paralysis. Eleven patients underwent neck surgery, thyroid surgery and cardiothoracic surgery and further examinations including laryn-geal electromyography and computed tomography help to determine the diagnosis were not performed. All patients were treated with inhaled corticosteroid conservatively. Five patients had significant improvement of symptom and almost regained normal voice. One patient had slight improvement and sixteen patients were not relieved before discharge.@*CONCLUSION@#Patients with hoarseness and vocal fold immobility after endotracheal intubation should be treated properly and immediately.

Learning curve for endoscopic evaluation of vocal folds lesions with narrow band imaging / Curva de aprendizado para avaliação endoscópica de lesões de pregas vocais com imagem de banda estreita

Abstract Introduction: The 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. Objective: The 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. Methods: Records 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. Results: The 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. Conclusions: A 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.

Resumo Introdução: Os métodos endoscópicos estão progredindo e se tornando comuns no diagnóstico clínico de rotina também na otorrinolaringologia. Um número relativamente grande de pesquisas demonstrou alta precisão na endoscopia com imagem de banda estreita na diferenciação de lesões benignas e malignas nas pregas vocais. Entretanto, pouco se sabe sobre a curva de aprendizado na avaliação da de banda estreita de lesões laríngeas. Objetivo: Determinar a curva de aprendizado para a avaliação por imagem de banda estreita das afecções das pregas vocais, de acordo com a duração do procedimento. Método: Foram incluídos no estudo 134 registros de imagens de banda estreita analisadas em termos da duração do procedimento e da acurácia do diagnóstico confirmado pelo diagnóstico histopatológico. Os exames com imagem de banda estreita foram feitos sequencialmente por um investigador por 18 meses. Resultados: A duração média dos registros de imagem de banda estreita foi de 127,82s. Todos os 134 estudos foram divididos em séries subsequentes de vários elementos. Uma evidente diminuição no tempo de investigação foi observada entre as séries 13 e 14, quando os exames foram divididos em séries de cinco elementos, o que corresponde à diferença entre o 65° e 70° exames de imagem de banda estreita subsequentes. Foram criados grupos paralelos de 67 exames. O grupo 1 incluiu o 1° ao 67° exame de imagem de banda estreita subsequente; Grupo 2 - o 68° ao 134° exame de imagem de banda estreita. O teste não paramétrico U de Mann-Whitney confirmou uma diferença estatisticamente significante entre a duração média do exame de imagem de banda estreita em ambos os grupos de 160,5s e 95,1s, respectivamente (p < 10-7). A sensibilidade e especificidade do exame de imagem de banda estreita no primeiro grupo foram, respectivamente: 83,7% e 76,7%. No segundo grupo, esses indicadores foram 98,1% e 80%, respectivamente. Conclusões: Um mínimo de 65 a 70 exames de imagem de banda estreita é necessário para se atingir a fase de estabilização (plateau) do processo de aprendizado na avaliação de lesões de glote. A análise das curvas de aprendizado é útil para o desenvolvimento de programas de treinamento e determinar o n.

Comparison of the efficacy of vocal training and vocal microsurgery in patients with early vocal fold polyp / Comparação entre a eficácia do treinamento vocal e da fonocirurgia em pacientes com pólipo de prega vocal incipiente

Abstract Introduction: Vocal fold polyp is a benign proliferative disease in the superficial lamina propria of the vocal fold, and vocal microsurgery can improve the voice quality of patients with vocal fold polyp. In preliminary studies, we found that vocal training could improve the vocal quality of patients with early vocal fold polyp. Objective: This study aimed to compare the efficacies of vocal training and vocal microsurgery in patients with early vocal fold polyp. Methods: A total of 38 patients with early vocal fold polyp underwent 3 months of vocal training (VT group); another 31 patients with early vocal fold polyp underwent vocal microsurgery (VM group). All subjects were assessed using laryngostroboscopy, voice handicap index, and dysphonia severity index, and the efficacies of vocal training and vocal microsurgery were compared. Results: The cure rates of vocal training and vocal microsurgery were 31.6% (12/38) and 100% (31/31), respectively. The intragroup paired-sample t-test showed that the post treatment vocal handicap index, maximum phonation time, highest frequency (F0-high), lowest intensity (I-low), and dysphonia severity index in both the VT and VM groups were better than those before treatment, except for the jitter value. The intergroup independent-sample t-test revealed that the emotional values of vocal handicap index (t = − 2.22, p = 0.03), maximum phonation time (t = 2.54, p = 0.013), jitter (t = − 2.11, p = 0.03), and dysphonia severity index (t = 3.24, p = 0.002) in the VT group were better than those in the VM group. Conclusions: Both, vocal training and vocal microsurgery could improve the voice quality of patients with early vocal fold polyp, and these methods present different advantages.

Resumo Introdução: O pólipo de prega vocal é uma doença proliferativa benigna da camada superficial da lâmina própria da prega vocal e a microfonocirurgia pode melhorar a qualidade vocal desses pacientes. Em estudos preliminares, observamos que o treinamento vocal era capaz de melhorar a qualidade vocal de pacientes com pólipo incipiente de prega vocal. Objetivo: Este estudo teve como objetivo comparar a eficiência entre treinamento vocal e microfonocirurgia em pacientes com pólipo incipiente de prega vocal. Método: Um total de 38 pacientes com pólipo incipiente de prega vocal foram submetidos a três meses de treinamento vocal (grupo TV); outros 31 pacientes foram submetidos à microfonocirurgia (grupo MC). Todos os indivíduos foram avaliados por meio de laringoestroboscopia, índice de desvantagem vocal e índice de severidade da disfonia e a eficácia entre treinamento vocal e microfonocirurgia foi comparada. Resultados: As taxas de cura do treinamento vocal e da microfonocirurgia foram de 31,6% (12/38) e 100% (31/31), respectivamente. O teste t para amostras pareadas intragrupo mostrou que o índice de desvantagem vocal pós-tratamento, tempo máximo de fonação, frequência máxima, intensidade mínima e índice de severidade da disfonia nos grupos TV e MC foram melhores do que aqueles antes do tratamento, exceto pelo valor do jitter. O teste t para amostras independentes intergrupos revelou que o valor emocional do índice de desvantagem vocal (t = -2,22, p = 0,03), tempo máximo de fonação (t = 2,54, p = 0,013), jitter (t = -2,11, p = 0,03) e índice de severidade da disfonia (t = 3,24, p = 0,002) no grupo TV foram melhores do que os do grupo MC. Conclusões: Tanto o treinamento vocal quanto a microfonocirurgia podem melhorar a qualidade da voz de pacientes com pólipo incipiente de prega vocal e esses métodos apresentam diferentes vantagens.

A morphological classification for vocal fold leukoplakia / Classificação morfológica das leucoplasias de prega vocal

Abstract Introduction: There is still no general method for discriminating between benign and malignant leukoplakia and identifying vocal fold leukoplakia. Objective: To evaluate the reliability of a morphological classification and the correlation between morphological types and pathological grades of vocal fold leukoplakia. Methods: A total of 375 patients with vocal fold leukoplakia between 2009 and 2015 were retrospectively reviewed. Two observers divided the vocal fold leukoplakia into flat and smooth, elevated and smooth, and rough type on the basis of morphological appearance. The inter-observer reliability was evaluated and the results of classification from both observers were compared with final pathological grades. Clinical characteristics between low risk and high risk group were also analyzed. Results: The percentage inter-observer agreement of the morphological classification was 78.7% (κ = 0.615, p < 0.001). In the results from both observers, the morphological types were significantly correlated with the pathological grades (p1 < 0.001, p2 < 0.001, Kruskal-Wallis test; r1 = 0.646, p1 < 0.001, r2 = 0.539, p2 < 0.001, Spearman Correlation Analysis). Multivariate analysis showed patient's age (p = 0.018), the size of lesion (p < 0.001), and morphological type (p < 0.001) were significantly different between low risk group and high risk group. Combined receiver operating characteristic curve analysis of significant parameters revealed an area under the receiver operating characteristic curve of 0.863 (95% CI 0.823-0.903, p < 0.001). Conclusions: The proposed morphological classification of vocal fold leukoplakia was consistent between observers and morphological types correlated with pathological grades. Patient's age, the size of lesion, and morphological type might enable risk stratification and provide treatment guidelines for vocal fold leukoplakia.

Resumo Introdução: Ainda não há um método universal estabelecido para diferenciar entre a leucoplasia benigna e maligna ou identificar as leucoplasias das pregas vocais. Objetivo: Avaliar a confiabilidade de uma classificação morfológica e a correlação entre os tipos morfológicos e os graus histopatológicos das leucoplasias de pregas vocais. Método: Os registros de 375 pacientes com leucoplasia da prega vocal assistidos entre 2009 e 2015 foram revisados retrospectivamente. Dois observadores dividiram a leucoplasia da prega vocal entre tipo plano e liso, elevado e liso, e rugoso, com base na aparência morfológica. A confiabilidade interobservador foi avaliada e os resultados de classificação de ambos os observadores foram comparados com os graus histopatológicos finais. As características clínicas entre os grupos de baixo risco e alto risco também foram analisadas. Resultados: A porcentagem da concordância interobservador da classificação morfológica foi de 78,7% (κ = 0,615, p < 0,001). Nos resultados de ambos os observadores, os tipos morfológicos correlacionaram-se significativamente com os graus histopatológicos (p1 < 0,001, p2 < 0,001, teste de Kruskal-Wallis; r1 = 0,646, p1 < 0,001, r2 = 0,539, p2 < 0,001, análise de correlação de Spearman). A análise multivariada mostrou que a idade do paciente (p = 0,018), o tamanho da lesão (p < 0,001) e o tipo morfológico (p < 0,001) foram significativamente diferentes entre o grupo de baixo risco e o de alto risco. A análise da curva ROC (Receiver Operating Characteristic) combinada de parâmetros significativos revelou uma área sob a curva de 0,863 (IC 95%: 0,823 ± 0,903, p < 0,001). Conclusões: A classificação morfológica proposta para leucoplasia de prega vocal foi consistente entre observadores e os tipos morfológicos correlacionaram-se com os graus histopatológicos. A idade do paciente, o tamanho da lesão e o tipo morfológico podem permitir a estratificação de risco e fornecem diretrizes de tratamento para a leucoplasia da prega vocal.

Split cricoídeo posterior endoscópico con injerto de cartílago costal / Endoscopic posterior cricoid split with costal cartilage graft

RESUMEN A pesar de los avances en cirugía de vía aérea, tanto abierta como endoscópica, la inmovilidad bilateral de cuerdas vocales continúa representando un desafio significativo para los cirujanos de vía aérea. Entre las alternativas quirúrgicas existen tanto abordajes endoscópicos como transcervicales, no obstante, la mayoría de estas técnicas modifican estructuralmente regiones de la cuerda vocal y/o aritenoides de manera permanente. La traqueostomía ha sido el tratamiento de elección en niños con inmovilidad bilateral de cuerdas vocales severamente sintomática, sin embargo, el procedimiento ideal debiese establecer una vía aérea adecuada evitando la necesidad de realizar una traqueostomía, y a la vez no generar un deterioro de la función fonatoria. La capacidad de expandir el aspecto glótico posterior sin modificación estructural de aritenoides y/o ligamento vocal ha convertido a la sección cricoidea posterior endoscópica con injerto de cartílago costal en una alternativa quirúrgica atractiva para estos casos. En este trabajo se realiza una revisión de la literatura y presenta un caso tratado mediante esta técnica en el Hospital Guillermo Grant Benavente de Concepción, Chile.

ABSTRACT Despite advances in both open and endoscopic airway surgery, bilateral vocal cord immobility still poses a significant challenge for airway surgeons. Among the surgical alternatives there are both endoscopic and transcervical approaches. However, most of these techniques structurally modify certain regions of the vocal cord and/or arytenoids permanently. Tracheostomy has been the treatment of choice in severely symptomatic children with bilateral immobility of vocal cords. Nevertheless, the ideal procedure should establish an adequate airway, avoiding the need to perform a tracheostomy, and at the same time not causing a deterioration of the phonatory function. The ability to expand the posterior glottis without structural modification of the arytenoids and/or vocal ligament has converted the posterior endoscopic cricoid split with costal cartilage graft into an attractive surgical alternative for these cases. In this article we review the literature and present a case treated by this technique in the Guillermo Grant Benavente Hospital in Concepción, Chile.

Effect of Hyaluronic Acid Injection for a Dysphagia Patient Who Has Unilateral Vocal Fold Paralysis due to a Lateral Medullary Infarction: A Case Report / 대한연하장애학회지

This paper reports a case of a female patient aged 48 years diagnosed with a right lateral medullary infarction and dysphagia after the onset period. In a video fluoroscopic swallowing study (VFSS), significant manifestations were not observed in the oral phase, but during swallowing aspiration, a larger amount of post-swallowing residue were observed on the test of swallowing of semisolid and liquid. After the VFSS, a laryngoscopy was performed, which indicated paralysis and para-median fixation in the right vocal fold. In this case, swallowing with rightward head rotation was adopted as a compensation technique to reduce the aspiration caused by the para-median fixation of the right vocal fold, but it was not enough to improve the dysphagia in this case. To medialize the right vocal fold, hyaluronic acid was injected with laryngoscopic guidance. In a VFSS conducted after the injection, aspiration was not observed on the test of swallowing a semisolid and liquid. The injection of hyaluronic acid is less invasive than surgical operations, does not require general anesthesia, and makes the recovery time shorter. Therefore, it is expected to be an alternative to the treatment of unilateral vocal fold paralysis (UVFP) accompanied with dysphagia.

Quantitative Measurement of Laryngeal Electromyography Using Motor Unit Action Potential in Unilateral Vocal Cord Paralysis

BACKGROUND AND OBJECTIVES: Laryngeal electromyography (LEMG) is valuable to evaluate the innervation status of the laryngeal muscles and the prognosis of vocal fold paralysis (VFP). However, there is a lack of agreement on quantitative interpretation of LEMG. The aim of this study is to measure the motor unit action potentials (MUAP) quantitatively in order to find cut-off values of amplitude, duration, phase for unilateral vocal fold paralysis patients. MATERIALS AND METHOD: Retrospective chart review was performed for the unilateral VFP patients who underwent LEMG from March 2016 to May 2018. Patient's demography, cause of VFP, vocal cord mobility, and LEMG finding were analyzed. The difference between normal and paralyzed vocal folds and cut-off values of duration, amplitude, and phase in MUAP were evaluated. RESULTS: Thirty-six patients were enrolled in this study. Paralyzed vocal fold had significantly longer duration (p=0.021), lower amplitude (p=0.000), and smaller phase (p=0.012) than the normal. The cut-off values of duration, amplitude, and phase in MUAP for unilateral VFP were 5.15 ms, 68.35 µV, and 1.85 respectively. CONCLUSION: An analysis of MUAP successfully provided quantitative differences between normal and paralyzed vocal folds. But, additional research is needed to get more available cut-off value which is helpful to evaluate the status of laryngeal innervations.

A Case of Unilateral Vocal Fold Paralysis Secondary to Sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Vocal fold paralysis secondary to sarcoidosis is extremely rare but it can develop as a result of compressive lymphadenopathy, granulomatous infiltration, and neural involvement. We report the case of a 56-year-old woman who presented with unilateral vocal fold paralysis and enlarged supraclavicular lymph nodes. Computed tomography of the neck revealed multiple, enlarged, and matted lymph nodes at the cervical level of IV. An ultrasound-guided core needle biopsy of the lymph node was performed, and a histopathological diagnosis of sarcoidosis was made by validating the presence of noncaseating granuloma. After implementation of steroid therapy, the patient exhibited immediate recovery from vocal fold paralysis. Although an extremely rare disease, sarcoidosis should be included in the differential diagnosis of vocal fold paralysis. Accurate diagnosis and prompt steroid treatment may reduce the morbidity of patients with vocal fold paralysis secondary to sarcoidosis.

A Case of Laryngeal Inflammatory Myofibroblastic Tumor / 대한두경부종양학회지

Inflammatory myofibrolastic tumor (IMT) is a rare borderline neoplasm. It frequently occurs in the lung but occasionally occurs in extrapulmonary sites such as the genitourinary tract, gastrointestinal tract, breast, salivary glands, sinonasal tract, orbit, and the central nervous system. Laryngeal involvement of IMT is very rare.A 61-year-old woman who complained of hoarseness persisting for 3 months visited our hospital. Laryngoscopy showed an elevated lesion in the right true vocal cord. Incisional biopsy was confirmed as larygeal inflammatory myofibrolastic tumor. We performed a transoral excision with CO2 LASER under suspension examination. Regional recurrence or distant metastasis was not observed after 9 months of follow-up. Herein we report a case of larygeal inflammatory myofibrolastic tumor that was treated with surgery alone, with a literature review.

Multidimensional effects of voice therapy in patients affected by unilateral vocal fold paralysis due to cancer / Efeitos multidimensionais da terapia vocal em pacientes com paralisia unilateral daprega vocal por câncer

Abstract Introduction: Patients with unilateral vocal fold paralysis may demonstrate different degrees of voice perturbation depending on the position of the paralyzed vocal fold. Understanding the effectiveness of voice therapy in this population may be an important coefficient to define the therapeutic approach. Objective: To evaluate the voice therapy effectiveness in the short, medium and long-term in patients with unilateral vocal fold paralysis and determine the risk factors for voice rehabilitation failure. Methods: Prospective study with 61 patients affected by unilateral vocal fold paralysis enrolled. Each subject had voice therapy with an experienced speech pathologist twice a week. A multidimensional assessment protocol was used pre-treatment and in three different times after voice treatment initiation: short-term (1-3 months), medium-term (4-6 months) and long-term (12 months); it included videoendoscopy, maximum phonation time, GRBASI scale, acoustic voice analysis and the portuguese version of the voice handicap index. Results: Multiple comparisons for GRBASI scale and VHI revealed statistically significant differences, except between medium and long term (p < 0.005). The data suggest that there is vocal improvement over time with stabilization results after 6 months (medium term). From the 28 patients with permanent unilateral vocal fold paralysis, 18 (69.2%) reached complete glottal closure following vocal therapy (p = 0.001). The logistic regression method indicated that the Jitter entered the final model as a risk factor for partial improvement. For every unit of increased Jitter, there was an increase of 0.1% (1.001) of the chance for partial improvement, which means an increase on no full improvement chance during rehabilitation. Conclusion: Vocal rehabilitation improves perceptual and acoustic voice parameters and voice handicap index, besides favor glottal closure in patients with unilateral vocal fold paralysis. The results were also permanent during the period of 1 year. The Jitter value, when elevated, is a risk factor for the voice therapy success.

Resumo Introdução: Pacientes com paralisia unilateral de prega vocal podem apresentar diferentes graus de distúrbios da voz, dependendo da posição da prega vocal paralisada. A compreensão da eficácia da terapia vocal nesta população pode ser um coeficiente importante para definir a abordagem terapêutica. Objetivo: Avaliar a eficácia da terapia vocal em curto, médio e longo prazos em pacientes com paralisia unilateral de prega vocal e determinar os fatores de risco para falha na reabilitação da voz. Método: Estudo prospectivo, no qual 61 pacientes com paralisia unilateral de prega vocal foram recrutados. Cada participante foi submetido a terapia vocal com um fonoaudiólogo experiente duas vezes por semana. Um protocolo de avaliação multidimensional foi utilizado no pré-tratamento e em três momentos após o início da terapia da voz: curto prazo (1-3 meses), médio prazo (4-6 meses) e longo prazo (12 meses); incluiu videoendoscopia, tempo máximo de fonação, escala GRBASI, análise de voz acústica e a versão em português do Voice Handicap Index. Resultados: Os dados comparativos temporais das avaliações revelaram diferenças estatisticamente significativas, exceto entre médio e longo prazo (p < 0,005). Os dados sugerem que há melhora vocal ao longo do tempo com resultados de estabilização após seis meses (médio prazo). Dos 28 pacientes com paralisia unilateral permanente da prega vocal, 18 (69,2%) atingiram o fechamento glótico completo após a terapia vocal (p = 0,001). O método de regressão logística indicou que o Jitter entrou no modelo final como um fator de risco para melhora parcial. Para cada unidade de aumento de Jitter, houve um aumento de 0,1% (1,001) da chance de melhora parcial, o que significa um aumento na chance de não ocorrer melhora completa durante a reabilitação. Conclusão: A reabilitação vocal melhora os parâmetros de voz perceptiva e acústica e o índice de incapacidade vocal, além de favorecer o fechamento glótico em pacientes com paralisia unilateral da prega vocal. Além disso, os resultados também foram permanentes durante o período de um ano. O valor de Jitter, quando elevado, é um fator de risco para sucesso parcial da terapia vocal.

The diagnostic value of laryngeal electromyography in vocal fold paralysis and arytenoid dislocation / 临床耳鼻咽喉头颈外科杂志

OBJECTIVES@#To identify diagnostic value of laryngeal electromyography (LEMG) in differentiating vocal fold paralysis (VFP) from arytenoid dislocation.@*METHODS@#The history, laryngeal morphologic characteristics and LEMG of 36 patients with VFP and 10 patients with arytenoid dislocation were compared and analyzed.@*RESULTS@#The most common cause of 36 VFP patients was surgical damage (24 cases), and the most common cause of 10 arytenoid dislocation patients was history of endotracheal intubation (9 cases). There was no statistical difference between the vocal fold and the fixed position of the vocal fold between the group of VFP patients and arytenoid dislocation patients. In the patients with VFP, 33 VFP patients (91.67%) had decreased recruitment; 9 cases (9/13) of denervation potential and 8 cases (8/9) of regeneration potential occurred within 1-6 months of the course of disease; 3 cases (3/4) of synkinesis occurred in the course of disease more than 6 months. In the patients with VFP, the amplitude (<0.01) and turns (<0.05) of thyroarytenoid muscles significantly decreased in the lesioned side comparing to the normal one, but the turns/amplitude ratio showed no statistical difference. In the patients with superior laryngeal nerve injury, the turns and amplitude analysis of cricothyroid muscles showed no statistical difference. All of 10 patients with arytenoid dislocation showed normal LEMG patterns.@*CONCLUSIONS@#LEMG can be used to differentiate the patients with vocal cord paralysis from arthrodesis dislocation, and can also carry out quantitative analysis to provide valuable help for the diagnosis.

Clinical analysis of vocal fold firbrous mass / 临床耳鼻咽喉头颈外科杂志

OBJECTIVES@#To explore the character of laryngoscopy finding, voice, and therapy of vocal fold fibrous mass.@*METHODS@#Clinical data, morphology, voice character, surgery and pathology of 15 cases with vocal fold fibrous mass were analyzed.@*RESULTS@#The morbidity of vocal fold fibrous mass might be related to overuse of voice and laryngopharyngeal reflex. Laryngoscopy revealed shuttle line appearance, smoothness and decreased mucosal wave of vocal fold. These patients were invalid for voice training and might be improved by surgery, but recovery is slow.@*CONCLUSIONS@#The morbidity of vocal fold fibrous mass might be related to overuse of voice and laryngopharyngeal reflex. Conservative treatment is ineffective for this disease, and surgery might improve.

Effects of Injection Laryngoplasty with Hyaluronic Acid in Patients with Vocal Fold Paralysis

OBJECTIVES: The purpose of this study was to explore the effects of injection laryngoplasty (IL) with hyaluronic acid in patients with vocal fold paralysis (VFP). METHODS: A total of 50 patients with VFP participated in this study. Pre- and post-IL assessments were performed, which included analyzing the sustained vowel /a/ phonation, and the patient reading 1 Korean sentence from the “Walk” passage that comprised 25 syllables in 10 words. To investigate the effect of IL on vocal fold function, acoustic analysis (acoustic voice quality index, cepstral peak prominence, maximum phonation time, speaking fundamental frequency) was conducted and auditory-perceptual (grade and overall severity), visual judgment (gap), and self-questionnaire (voice handicap index-10) assessments were performed. RESULTS: The patients with VFP showed statistically significant differences between pre-and post-IL assessments for acoustic and auditory-perception, visual judgment, and self-questionnaire assessments. CONCLUSION: The patients with VFP showed positive change in vocal fold function between pre- and post-IL measurements. The findings showed that IL with hyaluronic acid is an effective method to improve vocal fold function in patients with VFP.