Prospective Outcomes After Serial Platelet-Rich Plasma (PRP) Injection in Vocal Fold Scar and Sulcus.

OBJECTIVE: Vocal fold scar and sulcus pose significant treatment challenges with no current optimal treatment. Platelet-rich plasma (PRP), an autologous concentration of growth factors, holds promise for regenerating the superficial lamina propria. This study aims to evaluate the potential benefits of serial PRP injections on mucosal wave restoration and vocal function. METHODS: In a prospective clinical trial across two institutions, patients with vocal fold scar underwent four serial PRP injections, one month apart. Blinded independent laryngologists and expert listeners used pretreatment and one-month post-fourth injection videostroboscopy and CAPE-V assessments to evaluate mucosal wave and voice quality changes, respectively. Additionally, patient reported outcome measures (PROMs) were evaluated. RESULTS: In the study, 15 patients received 55 PRP injections without adverse effects. Eight patients (53.3%) had mild, three patients (20%) had moderate, and four patients (26.7%) had severe scar. There was an average reduction of 8.7 points in post-treatment VHI-10 scores (p = 0.007). The raters observed an improvement in post-treatment voice in 73.4% of cases, and CAPE-V scores showed a reduction of 18.8 points on average (p = 0.036). The videostroboscopic VALI ratings showed an improvement in mucosal wave rating from 2.0 to 4.0. On average, the raters perceived the post-PRP exams to be better in 56.7% of cases. CONCLUSIONS: PRP has been validated as a safe autologous option for treatment of vocal fold scar. While results for mucosal wave and voice quality varied, there was a consistent improvement in PROMs. LEVEL OF EVIDENCE: Level 3: Prospective cohort study, with blinded analysis Laryngoscope, 2024.

Intracordal Injection of Basic Fibroblast Growth Factor in 100 Cases of Vocal Fold Atrophy and Scar.

OBJECTIVES/HYPOTHESIS: Vocal fold atrophy, scar, and sulcus reduce the vibratory function of the vocal fold mucosa, which causes severe refractory dysphonia. We have reported encouraging preliminary results using an intracordal injection of basic fibroblast growth factor (bFGF) and showed improvement in phonatory parameters and voice. The present study summarizes our experience with 100 cases of stiffened vocal folds that were treated with bFGF injections. STUDY DESIGN: Retrospective chart review with Interstitial Review Board (IRB) approval. METHODS: Local injection of bFGF was performed in 100 cases of vocal fold pathology, which included 43 cases of vocal fold atrophy, 41 cases with scar, and 16 cases with sulcus. Ten micrograms of bFGF were injected into the vocal folds under topical anesthesia 4 times in each patient. Therapeutic outcomes were examined with maximum phonation time (MPT), voice handicap index-10 (VHI-10), and GRBAS scale. RESULTS: MPT, VHI-10, and GRBAS scores significantly improved in all pathology groups. An improvement on the VHI-10 greater than five points was observed in 82% of atrophy cases, 78% of scar cases, and 67% of sulcus cases. Improvement on the VHI-10 was significantly better in the atrophy group than the scar or sulcus groups. The mild/moderate cases of scar and sulcus showed better improvement than severe cases. CONCLUSIONS: The current large case series indicates positive effects of intracordal injection of bFGF for improvement of voice with no severe adverse events. The effects appeared best for cases of atrophy, while the treatment of severe scar and sulcus requires further improvement. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2059-2064, 2021.

Sulcus Vocalis: Results of Excision Without Reconstruction.

OBJECTIVE: Sulcus is an epithelial invagination of the membranous vocal fold. Its phonatory effects are usually attributed to fibrosis, thinning, and/or the absence of the superficial lamina propria (SLP). Surgical treatment is typically focused on reconstruction of the SLP. The purpose of this study is to assess the effects of excision without SLP reconstruction or replacement. METHODS: Records of patients who underwent surgical treatment of sulcus vocalis (Ford type 3) by excision without reconstruction were reviewed for demographic and historical information. Pre- and postoperative stroboscopic examinations were evaluated blindly by fellowship-trained laryngologists using a modified Voice-Vibratory Assessment with Laryngeal Imaging assessment. A Wilcoxon signed-rank test was used to compare pre- and postoperative amplitude, mucosal wave, nonvibrating portion, regularity, erythema, and vascularity. RESULTS: Examinations of 16 vocal folds in 13 patients (8 females:5 males; mean age = 30 years, range 13 to 48 years) were evaluated by six raters each, yielding 168 sets of observations. Statistically significant improvement was seen in amplitude (95% confidence interval [CI] 3.6,14.3), mucosal wave (95% CI 6.1, 17.9), nonvibrating portion (95% CI -19.6, -2.7), erythema (95% CI -19.9, -3.3), and vascularity (95% CI -19.0, -0.75). The parameter of regularity, although improved, did not prove to be significant. CONCLUSION: Excision alone appears to be an adequate and generally successful treatment for sulcus vocalis (Ford type 3). In contrast to established paradigms, restoration of the SLP does not appear to be essential to meaningful clinical improvement. Significant pathologic effects of sulcus vocalis may result from epithelial abnormalities alone. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2208-2212, 2020.

Sulcus Vocalis.

Sulcus vocalis, defined as a type of groove along the free edge of the vocal fold, disrupts the normal, pliable vocal fold cover, causing alterations in the intrinsic mucosal wave. The primary symptom is breathy, effortful dysphonia. Diagnosis may be challenging, and this classically has led to difficulties with identification and management. Treatment options, although often promising, have been notoriously unreliable. Current understanding, considerations for management, and future treatment options are explored.

[Clinical treatment of benign vocal cord lesions with occult vocal cord sulcus].

Objective:To discuss the correlation of benign vocal cord lesions with occult vocal cord sulcus and the treatment of benign vocal cord lesions with occult vocal cord sulcus, through the analysis of surgical data, preoperative voice evaluation data and postoperative follow-up data of patients.Method:The data from 377 patients of benign vocal cord lesions with concealed vocal cord sulcus admitted to Beijing Tongren Hospital from 2005 to 2016 were reviewed. The follow-up time was more than half a year after surgery.Result:About 2.9% of the benign lesions of the vocal cords were associated with occult vocal cords sulcus,of which 61.27% were bilateral vocal cords sulcus,22.55% was right vocal cords sulcus,and 16.18% was left vocal cord sulcus.Of the patients with bilateral vocal fold sulcus,64.5% had benign vocal cord lesions and 35.5% had unilateral vocal cord benign lesions.Of the patients with unilateral vocal fold,73.97% were associated with ipsilateral vocal cord benign lesions, and 26.03% were associated with contralateral vocal cord lesions.In the 531 sides of the vocal cords sulcus,183 sides of vocal fold sulcus typeⅠwere not treated. The 332 sides of vocal fold sulcus type Ⅱ were treated with removed lesions of the vocal cords and microdissection of vocal cord adhesion.The 16 sides of vocal fold sulcus type Ⅲ were treated with removed lesions of the vocal cords,local tamponaded of autogenous abdominal fascia and microsutured to close the wound. There were 9 cases with 11 sides of vocal fold sulcus combined with the mucous bridge.The satisfactory rate of sound improvement was 80.37% in half a year after the operation.Postoperative fundamental frequency,jitter,shimmer and maximum phonation time were significantly improved compared with preoperative.Conclusion:The occurrence of benign vocal cord lesions may be related to occult vocal fold sulcus.Simultaneous treatment of benign vocal cord lesions with occult vocal cord sulcus can achieve satisfactory voice improvement.Therefore, we should pay attention to the treatment of vocal fold sulcus in the diagnosis and treatment of benign vocal cord diseases.

Sulcus vocalis: A new clinical paradigm based on a re-evaluation of histology.

OBJECTIVES/HYPOTHESIS: Sulcus vocalis is an epithelial invagination adherent to deep tissues of the vocal fold. Traditionally, dysphonia is believed to result from attenuation or absence of lamina propria and consequent alteration of mucosal dynamics. This conception does not account for several clinical features of the lesion, most notably inflammation. The goal of this study is to elucidate the clinical nature of sulcus by re-examination of its histopathology. STUDY DESIGN: Retrospective review. METHODS: Clinical features, including stroboscopic examination, and hematoxylin and eosin sections of 19 lesions in 15 patients who underwent surgery were reviewed. RESULTS: Epithelial change was found uniformly in all specimens, consisting of parakeratosis (78.9%), epithelial thickening (77.8%), dyskeratosis (63.2%), basement membrane thickening (47%), epithelial inflammation (52.6%), and retention of keratin debris (36.8%). In contrast, submucosal findings were less prevalent. Seven patients (36.8%) had essentially normal subepithelial tissues. Submucosal inflammation was present in seven (36.8%), and other submucosal changes in four of 17 (23.5%). Clinical characteristics demonstrated general improvement after surgical intervention in most cases. CONCLUSIONS: Sulcus vocalis appears to have an important component of epithelial pathology, with especially high prevalence of parakeratosis, dyskeratosis, and epithelial thickening. Clinical changes may result from prominent perilesional inflammation related to epithelial changes instead of or in addition to any alteration of the lamina propria. Surgical treatment, when necessary, should refocus on removal of pathologic epithelium as a source of inflammation independent of reconstructive considerations. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:1397-1403, 2016.