Heavier Weight of Resected Thyroid Specimen Is Associated With Higher Postoperative Morbidity in Benign Goiter.

OBJECTIVE: The impact of heavier weight of resected thyroid specimen on postoperative morbidity after total thyroidectomy for multinodular benign goiter remains unclear. METHODS: Data from the prospective StuDoQ|Thyroid registry of the German Society of General and Visceral Surgery were analyzed regarding the weight of the resected thyroid specimen and perioperative morbidity (vocal cord palsy, hemorrhage, surgical site infection, and hypocalcemia). To achieve a homogeneous patient population, only patients with total thyroidectomy for multinodular benign goiter were included. RESULTS: A total of 7911 patients from 105 departments underwent total thyroidectomy for benign conditions (January 2017-July 2020). The median resected weight of the thyroid specimen in all patients was 53 g (interquartile range 32-92). In 1732 patients, the specimen weight exceeded 100 g. Intraoperative neuromonitoring was used in 99.5% of patients. Postoperative laryngoscopy revealed vocal cord dysfunction in 480 of 15 822 (3.03%) nerves at risk, with unilateral dysfunction in 454 (2.87%) of patients and bilateral dysfunction in 13 patients (0.08%). In multivariable analysis, a thyroid weight >100 g was an independent predictor of early postoperative vocal cord dysfunction [odds ratio (OR) 1.462, 95% CI 1.108-1.930, P = 0.007). Heavier (>100 g) thyroid weight was an independent predictor of surgical site infection (OR 1.861, 95% CI 1.203-2.880, P = 0.005) and also predicted postoperative hemorrhage in the univariate analysis (OR 1.723, 95% CI 1.027-2.889, P = 0.039). On the contrary, postoperative parathyroid function was not affected. CONCLUSIONS: Heavier (>100 g) resected thyroid weight independently predicts higher postoperative morbidity, including early vocal cord palsy and surgical site infection after total thyroidectomy for benign multinodular goiter.

Voice outcome after vocal fold injection augmentation with carboxymethyl cellulose versus calcium hydroxyapatite.

BACKGROUND: Vocal fold injection augmentation is a recognised treatment modality for glottic insufficiency. Causes of glottal closure insufficiency include vocal fold paralysis, paresis, atrophy, sulcus vocalis, scarring and vocal fold deficiency after laryngeal surgery. A variety of materials exist for injection augmentation. This study aimed to compare voice improvement after injection augmentation between two injectable materials: carboxymethyl cellulose and calcium hydroxyapatite. METHOD: This retrospective study included 66 consecutive patients with glottic insufficiency who underwent injection augmentation. RESULTS: Among the patients who received their first injection augmentation with carboxymethyl cellulose and their second injection augmentation with calcium hydroxyapatite (n = 28), voice quality improved significantly after both injection augmentations. No significant differences were observed in any of the objective and subjective voice quality measurements examined following carboxymethyl cellulose and calcium hydroxyapatite injections. CONCLUSION: Voice improvement after injection augmentation depends mainly on the improvement of glottic closure, rather than the injection material.

Predictors of voice outcome in pediatric non-selective laryngeal reinnervation.

OBJECTIVES: Non-selective laryngeal reinnervation (NSLR) using the ansa cervicalis to the recurrent laryngeal nerve (RLN) is a promising treatment option for pediatric unilateral neuronal vocal fold movement impairment (VFMI). The aim is to describe our clinical outcomes with this technique and to identify preoperative characteristics that may predict postoperative voice outcomes. METHODS: This is a cohort study of pediatric patients with unilateral neuronal VFMI, who underwent NSLR from March 2012 to July 2018. Pre- and postoperative Pediatric Voice Related Quality of Life (PVRQOL) questionnaires, Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) ratings, and objective voice measures were obtained. In addition, patients underwent preoperative laryngeal electromyography (LEMG). RESULTS: Thirty-two patients were identified. Twenty-one had complete data sets for analysis. The mean duration of VFMI was 9.02 years (range 1.1-26.1 years). There were significant improvements in PVRQOL (P = .0005), in all CAPE-V subsets (P ≤ .0001 to .0195), mean and maximum intensities (P = .0342 and 0.0110, respectively), cepstral peak prominence (P = .0001), and cepstral spectral index of dysphonia (P ≤ .0001). A worse preoperative LEMG correlated with a greater change in maximum phonation time (P = .0162) and maximum intensity (P = .0346). Age at injury and duration of injury had no significant impact on voice outcomes; however, patients with concurrent posterior glottic insufficiency did have smaller changes in PVRQOL (P = .012). CONCLUSION: NSLR is an effective treatment for pediatric unilateral neuronal VFMI even many years after initial RLN injury. LEMG may help predict voice outcomes of reinnervation in pediatric patients, but further data is still needed. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1525-1531, 2020.

History conflict and non-formulary medicine: a threat for anaesthesiologist in low and middle-income countries.

The practice of complementary and non-formulary medicine has gained tremendous popularity due to their claimed beneficial effects in cardiac, respiratory and chronic diseases, as also other disorders. The most threatening aspect related to these practices pertains to the non-disclosure of its use by patients at the time of their preoperative assessment in elective or emergency setting. We report a case of profound, long-lasting unexplained hypotension during and after anaesthesia in a patient presented for emergency vocal cord surgery (cordectomy). He was taking complementary medicine for last 2 years. Serum cortisol level was sent postoperatively in intensive care unit that was found extremely low.

Impact of vocal fold augmentation and laryngoplasty on dyspnea in patients with glottal incompetence.

OBJECTIVES/HYPOTHESIS: Given that the vocal folds are active organs of respiration, reports of dyspnea in the context of glottic insufficiency are not uncommon. We hypothesize that improved glottal closure via framework surgery or vocal fold augmentation improves dyspnea symptoms. STUDY DESIGN: Retrospective review. METHODS: Charts of patients undergoing procedures to correct glottal insufficiency, either via vocal fold augmentation (VFA) or medialization laryngoplasty (ML) between December 2012 and September 2015 were reviewed (n = 189). Modified Borg Dyspnea Scale (MBDS) and Modified Medical Research Council Dyspnea Scale (MMRCDS) data were collected before and after intervention. Age, body mass index (BMI), and sex, as well as pulmonary and cardiac comorbidities were considered. Subgroup analysis was performed on individuals with subjective dyspnea prior to intervention. RESULTS: For the entire cohort, differences in the MMRCDS and MBDS were not statistically different pre- and postintervention (P = .20 and P = .12, respectively). Patients with BMI <30 experienced more improvement on the MBDS (P = .03). Both the MMRCDS and MMBDS improved post-procedure (P = .001 and P = .001, respectively) in patients reporting dyspnea prior to intervention. CONCLUSIONS: Patients with glottic insufficiency and dyspnea prior to intervention to improve glottic closure had a significant reduction in dyspnea following treatment. Conversely, subjects without complaints of dyspnea prior to intervention had variable outcomes with regard to dyspnea symptoms. Additionally, based on data from the entire cohort, VFA or ML did not worsen dyspnea symptoms. These data may assist in counseling and/or selection of patients considered for procedures to improve glottic closure. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:427-429, 2018.

Revisión de nuestra experiencia en fonocirugía infantil / A review of our experience in phonosurgery in children

Introducción y objetivos: La disfonía es un problema frecuente en los niños, especialmente en edad escolar. La exploración de las cuerdas vocales suele ser más difícil y menos precisa que en los adultos. La lesión que más a menudo encontramos en niños con disfonía crónica son los nódulos vocales, seguido de los quistes epidermoides y de las demás lesiones congénitas, como sulcus y puente mucoso. El tratamiento es multidisciplinar y se basa fundamentalmente en rehabilitación vocal. Indicamos tratamiento quirúrgico en niños mayores de 9 años en los que persiste el problema tras la rehabilitación, sobre todo si sospechamos una lesión congénita de la cuerda vocal. Métodos: Presentamos un estudio retrospectivo de la fonocirugía infantil realizada en nuestro hospital durante 9 años (2005-2013). Se incluye a 51 niños, con edades comprendidas entre los 9 y los 16 años. Analizamos la distribución de las diferentes lesiones, tanto congénitas como adquiridas. Evaluamos los resultados mediante la valoración subjetiva de los familiares de los niños intervenidos. Resultados: Obtuvimos una distribución del 76% (n = 39) de lesiones congénitas y un 24% (n = 12) de lesiones adquiridas. Encontramos un porcentaje global de mejoría tras la cirugía del 90%, con mejores resultados en los nódulos vocales, aunque sin alcanzar significación estadística.Conclusiones: La valoración de los resultados de esta cirugía es controvertida y en este estudio se hace con una única pregunta a los familiares. Encontramos un resultado global de mejoría en el 90% de los casos intervenidos, sin ninguna complicación. Tenemos mejores resultados con los nódulos vocales, aunque no alcanzan significación estadística (AU)

Introduction and objectives: Dysphonia is a common problem in children, especially those of school age. Exploration of vocal folds is often difficult and less accurate in children. The most frequent lesions found in children with chronic dysphonia are vocal nodules, followed by epidermoid cysts and other congenital lesions, such as sulci and mucosal bridges. The treatment is multidisciplinary and it is fundamentally based on vocal rehabilitation. We indicate surgical treatment in children older than 9 years of age for whom the problem persists after rehabilitation, especially if we suspect a congenital lesion of the vocal fold. Methods: We present a retrospective study of paediatric phonosurgery performed by the Vocal Pathology Unit of our Hospital over a period of 9 years (2005-2013). Fifty-one children were included, ranging in age from 9 to 16 years old. We analyzed the distribution of the different lesions, both congenital and acquired. We evaluated the results by subjective evaluation by the children's relatives. Results: We obtained a distribution of 76% (n = 39) of congenital lesions and 24% (n = 12) of acquired lesions. After surgery, there was a global percentage of improvement of 90%, with better results in cases of vocal nodules, without statistical significance. Conclusions: The evaluation of the results of this surgery is controversial and in this study is done with a single question survey administered to relatives. We found an overall result of improvement in 90% of operated cases, without any complications. We obtained better results in vocal nodules, although not reaching statistical significance (AU)

[A Case of Idiopathic Bridging Vocal Fold Adhesion that was Treated by Ambulatory Surgery under Local Anesthesia].

Patients with vocal fold adhesions usually undergo surgery under general anesthesia, because of the possibility of postoperative adhesions according to the severity and cause. However, it has been reported that patients with minor bridging adhesion can be treated by only discission without any postoperative adhesion. Herein, we report the case of a patient with idiopathic bridging vocal fold adhesions who was treated by ambulatory surgery at the ENT clinic and showed a benign course. A male former professional singer who was in his 70s presented with a history of cough followed by the development of bridging central vocal fold adhesion. On the 10th day after the initial visit, we performed discission of the adhesion under local anesthesia using a surgical knife for the vocal fold. Although a delicate surgical technique is desirable for phonosurgery, we were able to perform surgery under local anesthesia in this case, because the adhesion was minor. We consider that endoscopic laryngeal surgery under local anesthesia is useful for the treatment of patients with bridging adhesions.

Does treatment of paradoxical vocal fold movement disorder decrease asthma medication use?

OBJECTIVES/HYPOTHESIS: To determine whether diagnosis and treatment of paradoxical vocal fold movement disorder (PVFMD) leads to decreased asthma medication use. Secondary objectives include determining initial rate of asthma medication use, characterizing symptom improvement, and correlating with pulmonary function testing (PFT). STUDY DESIGN: Prospective observational study. METHODS: Patients newly diagnosed with PVFMD at a single institution were recruited to participate. Medication questionnaires were completed at the initial visit, at the first return visit for therapy, and at 6 months. PFTs were reviewed when available. RESULTS: Sixty-six patients were recruited; the study was closed early because findings reached significance. Fifty-six patients (85%) were taking asthma medication at presentation. Forty-four patients presented with PFTs, and two-thirds were normal. Forty-two patients completed follow-up questionnaires; 79% decreased asthma medication use (P < .001), and 82% reported symptom improvement. Seventy-seven percent of patients participated in therapy and 23% did not, with equal rates of decrease in asthma medication use between these groups. Outcomes did not vary based on PFT pattern (i.e., obstructive vs. nonobstructive, P = .75). CONCLUSIONS: Diagnosis and treatment of PVFMD lead to a decline in asthma medication use. This decrease occurred alongside symptom improvement and irrespective of PFT findings. Use of asthma medication in this patient population is high, at 85%. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1531-1537, 2017.

[Surgery of benign vocal fold lesions]. / Chirurgie gutartiger Stimmlippenbefunde.

Surgical treatment of benign vocal fold lesions can be indicated for clinical or functional reasons. The principles of phonosurgery have to be maintained in either case. The appropriate phonosurgical technique depends on the type of vocal fold lesion. Depending on the findings, phonosurgery aims to maintain or improve voice quality. The evaluation of clinical and functional results includes indirect laryngoscopy, videostroboscopy, and voice analysis.

Vocal fold hyalinosis in Urbach-Wiethe disease, a rare cause of hoarseness.

BACKGROUND: Lipoid proteinosis is an autosomal recessive disorder characterized by hyalin deposits in the skin and mucosa of the upper aerodigestive tract; currently, no treatment exists. Nearly all patients experience hoarseness and speech difficulties, due to hyalin deposition in the vocal folds and diminished mobility in infiltrated lips, tongue, and palate. METHODS: We describe a patient with extensive hyalin plaques on the vocal folds, which resulted in near-aphonic hoarseness. Hyalin deposits in the vocal folds and skin were treated with laser resection. RESULTS: Both the vocal folds and skin improved in appearance, with smoother surface epithelium. However, the patient's speech remained impaired, due to extensive hyalin plaques in the mouth, tongue, and lips. The voice improved only temporarily. CONCLUSIONS: Laser resection of hyalin plaques in the vocal folds and skin is a feasible treatment for lipoid proteinosis. However, speech may remain severely limited, due to impaired tongue and lip movement.

The effect of voice rest on the outcome of phonosurgery for benign laryngeal lesions: preliminary results of a prospective randomized study.

OBJECTIVES: According to the literature, voice rest following phonosurgery, as recommended in clinical practice, varies between 3 and 7 days. However, up until now, no randomized trials have been published comparing voice rest of short versus long duration. METHODS: This is an ongoing prospective randomized study, comparing strict voice rest of 5 versus 10 days on the voice following phonosurgery. Thirty-one elective patients operated on for benign laryngeal lesions were randomized. They completed pre- and postoperative assessments, including perceptual voice quality (Grade, Roughness, Breathiness, Asthenia, Strain, Instability scale), Voice Handicap Index total score, and voice analysis with both acoustic and aerodynamic measurements. Additional factors such as smoking, vocal abuse, reflux, and preoperative speech therapy were also taken into account. RESULTS: Sixteen patients were randomized to follow 5 days' voice rest and 15 patients were randomized to 10 days' voice rest. Statistical analysis showed no significant differences in pre- or postoperative measurements between the 2 groups. However, multilinear regression analysis for the effect of voice rest duration on postoperative values showed a significant improvement in maximum phonation time (MPT) with 10 days' voice rest. CONCLUSIONS: Preliminary results show a benefit of prolonged voice rest (10 days' duration) on MPT.

Autologous fat augmentation of the vocal folds.

Autologous fat augmentation of the vocal folds has become widely adopted as a means of vocal rehabilitation in patients with deficient glottal closure. In general, the injection method using autologous tissues has no problems regarding safety issues such as infection of unknown cause, but the period of continuous effect is not constant because absorption may occur after injection. In 99 cases during the 8-years from August 2003 to April 2011. The details of postoperative course were reported. In a cases, maximum phonation time was improved.

The digital AcuBlade laser system to remove huge vocal fold granulations following subglottic airway stent.

We report a case of granulations that complicated subglottic stent placement and completely destroyed vocal folds with luminal stent obstruction. A microbial aetiology significantly contributed to the occurrence of granulations associated with mechanical irritation. The granulations were successfully resected using a digital AcuBlade laser system, a new generation of CO2 laser used in otorhinolaryngology, particularly in vocal cord disease. It permitted a precise control of the scan line between vocal fold and granulation for several reasons. The scan line was completely electronic and integrated in the scanner. The sweep in speed was constant and the energy distribution was uniform along the entire length of the time. The interpulse pause was of ∼1 ms, allowing the tissue cooling with reduction of thermal spread and quicker healing support. The result was the radical excision of granulations without injuring vocal folds. The respiratory function was restored and no other treatments such as arytenoidectomy or cordectomy associated with the alteration of phonatry function were required. No intraoperative or/and postoperative complications were registered and the patient was discharged 7 days after the procedure.