Cricothyroid Dysfunction in Unilateral Vocal Fold Paralysis Females Impairs Lexical Tone Production.

In this cross-sectional study, we compared voice tone and activities relating to the laryngeal muscle between unilateral vocal fold paralysis (UVFP) patients with and without cricothyroid (CT) muscle dysfunction to define how CT dysfunction affects language tone. Eighty-eight female surgery-related UVFP patients were recruited and received acoustic voice analysis and laryngeal electromyography (LEMG) when the patient was producing the four Mandarin tones. The statistical analysis was compared between UVFP patients with (CT+ group, 17 patients) and without CT muscle (CT- group, 71 patients) involvement. When producing Mandarin Tone 2, the voice tone in the CT+ group had smaller rise range (p = 0.007), lower rise rate (p = 0.002), and lower fundamental frequency (F0) at the offset point of the voice (p = 0.023). When producing Mandarin Tone 4, the voice tone in the CT+ group had smaller drop range (p = 0.019), lower drop rate (p = 0.005), and lower F0 at voice onset (p = 0.025). The CT+ group had significantly lower CT muscle activity when producing the four Mandarin tones. In conclusion, CT dysfunction causes a limitation of high-rising tone in Tone 2 and high-falling tone in Tone 4, a property that dramatically limits the tonal characteristics in Mandarin, a tonal language. This limitation could further impair the patient's communication ability.

Outcomes of Esophageal Cancer after Esophagectomy in the Era of Early Injection Laryngoplasty.

(1) Background: severe weight loss was reported to be related to unilateral vocal fold paralysis (UVFP) after esophagectomy and could thus impair survival. Concomitant radical lymph node dissection along the recurrent laryngeal nerve during esophageal cancer surgery is controversial, as it might induce UVFP. Early intervention for esophagectomy-related UVFP by administering intracordal injections of temporal agents has recently become popular. This study investigated the survival outcomes of esophagectomy for esophageal squamous cell carcinoma (ESCC) after the introduction of early injection laryngoplasty (EIL). (2) Methods: a retrospective review of patients with ESCC after curative-intent esophagectomy was conducted in a tertiary referral medical center. The necessity of EIL with hyaluronic acid was comprehensively discussed for all symptomatic UVFP patients. The survival outcomes and related risk factors of ESCC were evaluated. (3) Results: among the cohort of 358 consecutive patients who underwent esophagectomy for ESCC, 42 (11.7%) showed postsurgical UVFP. Twenty-nine of them received office-based EIL. After EIL, the glottal gap area, maximum phonation time and voice outcome survey showed significant improvement at one, three and six months measurements. The number of lymph nodes in the resected specimen was higher in those with UVFP than in those without UVFP (30.1 ± 15.7 vs. 24.6 ± 12.7, p = 0.011). The Kaplan-Meier overall survival was significantly better in patients who had UVFP (p = 0.014), received neck anastomosis (p = 0.004), underwent endoscopic resection (p < 0.001) and had early-stage cancer (p < 0.001). Multivariate Cox logistic regression analysis showed two independent predictors of OS, showing that the primary stage and anastomosis type are the two independent predictors of OS. (4) Conclusion: EIL is effective in improving UVFP-related symptoms, thus providing compensatory and palliative measures to ensure the patient's postsurgical quality of life. The emerging use of EIL might encourage cancer surgeons to radically dissect lymph nodes along the recurrent laryngeal nerve, thus changing the survival trend.

Clinical and functional characteristics of lung surgery-related vocal fold palsy.

BACKGROUND: Unilateral vocal fold paralysis (UVFP) caused by lung surgery is associated with prolonged hospital stay and increased postoperative comorbidities. We evaluated lung surgery-related UVFP and compared its characteristics with UVFP caused by esophageal and thyroid surgeries, as the most common surgical causes of UVFP. We also evaluated the outcomes of intracordal hyaluronate injection laryngoplasty in these patients. METHODS: Patients with surgery-related UVFP were evaluated by quantitative laryngeal electromyography, videolaryngostroboscopy, voice acoustic analysis, Voice Outcome Survey (VOS) questionnaire, and Short Form-36 Health Survey (SF-36) quality-of-life questionnaire. Data for the lung, esophageal, and thyroid surgery groups were compared and changes in outcome measurements induced by hyaluronate injection were compared among the three groups. RESULTS: A total of 141 patients were recruited, including 21, 46, and 74 in the lung, esophageal, and thyroid surgery groups, respectively. Compared with the other two groups, lung surgery patients had predominantly left-sided UVFP, less involvement of the external branch of the superior laryngeal nerve, and higher jitter. Most outcome measurements improved in all three groups after office-based hyaluronate injection, with the greatest improvement in jitter in the lung surgery group. CONCLUSIONS: Lung surgery-related UVFP showed a distinct disease presentation, and patients' voice parameters and quality of life recovered dramatically after office-based hyaluronate injection. We recommend evaluation of lung surgery-related UVFP and early intervention, such as office-based hyaluronate injection, to improve patients' voice function and quality of life.

Two trajectories of functional recovery in thyroid surgery related unilateral vocal cord paralysis.

BACKGROUND: Iatrogenic unilateral vocal fold paralysis caused by thyroid surgery induces profound physical and psychosocial distress in patients. The natural course of functional recovery over time differs substantially across subjects, but the mechanisms underlying this difference remain unclear. In this study, we examined whether the anatomic site of the lesion affected the trajectory of recovery. METHODS: In this prospective case series study in a single medical center, patients with thyroid surgery-related unilateral vocal fold paralysis were evaluated using quantitative laryngeal electromyography, videolaryngostroboscopy, voice acoustic analysis, the Voice Outcome Survey, and the Short Form-36 quality-of-life questionnaire. Patients with and without superior laryngeal nerve injuries were compared. RESULTS: Forty-two patients were recruited, among whom 15 and 27 were assigned to the with and without superior laryngeal nerve injury groups, respectively. Compared with the group without superior laryngeal nerve injury, the group with superior laryngeal nerve injury group demonstrated less improvement in the recruitment of vocal fold adductors, and the group also had more severe impairment of vocal fold vibration, maximum phonation time, jitter, shimmer, and harmony-to-noise ratio at the first evaluation. This difference was also found in the glottal gap and maximum phonation time 12 months after the injury. CONCLUSION: Among patients with thyroid surgery-related unilateral vocal fold paralysis, superior laryngeal nerve injury induces a distinctively different recovery trajectory compared with those without superior laryngeal nerve injury characterized by less reinnervation of vocal fold adductors and worse presentation in terms of the glottal gap and maximum phonation time. This study emphasizes the importance of superior laryngeal nerve function and its preservation in thyroid surgery.

Voice aerodynamics following office-based hyaluronate injection laryngoplasty.

OBJECTIVES: Neuromuscular control, glottal conformation and aerodynamics are the major factors affecting voice performance. We aimed to characterise the degree to which voice improvements following office-based intracordal hyaluronate injection laryngoplasty (HIL) depend on changes in voice aerodynamics in patients with unilateral vocal fold paralysis (UVFP), by assessing the correlations between these parameters. DESIGN: Prospective case series. SETTING: Otolaryngology Clinics in a Medical Center. PARTICIPANTS: Patients with UVFP within 6 months of their first outpatient visit who received single HIL. MAIN OUTCOME MEASURES: Videolaryngostroboscopy, aerodynamics and laboratory voice analysis were evaluated at baseline and 1 month after HIL. Quantitative laryngeal electromyography was evaluated at baseline to confirm UVFP. RESULTS: Seventy-five newly diagnosed patients with UVFP were analysed. The normalised glottal gap area (NGGA) decreased (P < 0.001) (Cohen's dz  = 0.94) and all aerodynamic parameters improved (all P < 0.05) (Cohen's dz  = 0.38-1.02) following HIL. Patients undergoing thoracic surgery had more profound aerodynamic impairments both before and after HIL. After adjusting for improvements in NGGA, the improvement in aerodynamics was correlated with voice improvement and most notably with maximum phonation time and jitter/shimmer. CONCLUSIONS: Hyaluronate injection laryngoplasty improved glottal conformation, aerodynamics and voice, highlighting the benefit of early HIL intervention for patients with UVFP. Patients with UVFP caused by thoracic surgery continued to have poorer aerodynamics post-HIL, indicating the importance of speech therapy in these patients.

Disease Characteristics and Electromyographic Findings of Nonsurgery-Related Unilateral Vocal Fold Paralysis.

OBJECTIVE: The detailed characteristics and prognosis of nonsurgery-related unilateral vocal fold paralysis (NSUVFP) are currently unclear. This study evaluated the extent of laryngeal nerve lesions and the individual characteristics for patients with NSUVFP. STUDY DESIGN: Retrospective, case series. METHODS: Patients with unilateral vocal fold paralysis (UVFP) were evaluated using videolaryngostroboscopy and quantitative laryngeal electromyography. The side of nerve lesions, involvement of the external branch of the superior laryngeal nerve (eSLN), and complete vocal fold motion recovery were evaluated after ≥ 6 month follow-up. RESULTS: A total of 207 UVFP patients were recruited, including 153 surgery-related UVFP and 54 NSUVFP patients. Thirty-four (63%) and 20 (37%) NSUVFP patients were further assigned to idiopathic and nonsurgery-related-nonidiopathic (NSNI) groups, respectively. In the idiopathic group, eSLN lesions occurred in all six (100%) patients with right-side paralysis, but in only six of 28 (21%) patients with left-side paralysis (P < 0.001). The turn frequency of the paralyzed thyroarytenoid-lateral cricoarytenoid muscle complex is lower in the NSNI group (333.1 ± 192.1) compared with the idiopathic group (490.2 ± 255.1) (P = 0.02). The probability of complete vocal fold motion recovery did not differ among groups (P > 0.05). CONCLUSION: Idiopathic and NSNI UVFP have different clinical presentations defined by laryngeal electromyography. NSNI UVFP had more severe denervation changes compared with idiopathic UVFP. These results may support two pathogenic mechanisms for idiopathic UVFP: 1) neuropathy specifically involving left recurrent laryngeal nerve (RLN), and 2) neuropathy affecting nerves proximal to the RLN. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1381-1387, 2017.

Distinct Disease and Functional Characteristics of Thyroid Surgery-Related Vocal Fold Palsy.

BACKGROUND: Iatrogenic trauma induced by thyroid surgery is the most common etiology of unilateral vocal fold paralysis (UVFP). UVFP after thyroid surgery may lead to profound physical and psychosocial distress. This study comprehensively evaluated UVFP caused by thyroid surgery, and compared the results with those caused by other surgical trauma. METHODS: Patients with surgery-related UVFP were evaluated using quantitative laryngeal electromyography, videolaryngostroboscopy, voice acoustic analysis, the Voice Outcome Survey, and the Short Form-36 Health Survey quality-of-life questionnaire. Patients with thyroid surgery and other surgeries were compared. RESULTS: A total of 105 patients were recruited, of whom 52 and 53 were assigned to the thyroid surgery and the other surgery group, respectively. Patients in the thyroid surgery group had a higher proportion of external branch of superior laryngeal nerve (eSLN) involvement, longer duration from disease onset to the first laryngeal electromyography examination, lower jitter, higher harmonic-to-noise ratio, and better quality of life compared with the other surgery group. Specifically for patients in the thyroid surgery group, those with eSLN involvement tended to have more pronounced impairment in jitter and shimmer compared with patients without eSLN involvement. CONCLUSION: UVFP caused by thyroid surgery has a distinct clinical presentation with relatively high involvement in the eSLN, better voice acoustics, longer waiting time before asking for evaluation, and less impact on quality of life. The involvement of eSLN in these patients further impaired their voice. Early referral is suggested for these patients, especially with suspected eSLN injury.

Quantitative electromyographic characteristics of idiopathic unilateral vocal fold paralysis.

OBJECTIVES/HYPOTHESIS: Unilateral vocal fold paralysis with no preceding causes is diagnosed as idiopathic unilateral vocal fold paralysis. However, comprehensive guidelines for evaluating the defining characteristics of idiopathic unilateral vocal fold paralysis are still lacking. In the present study, we hypothesized that idiopathic unilateral vocal fold paralysis may have different clinical and neurologic characteristics from unilateral vocal fold paralysis caused by surgical trauma. STUDY DESIGN: Retrospective, case series study. METHODS: Patients with unilateral vocal fold paralysis were evaluated using quantitative laryngeal electromyography, videolaryngostroboscopy, voice acoustic analysis, the Voice Outcome Survey, and the Short Form-36 Health Survey quality-of-life questionnaire. Patients with idiopathic and iatrogenic vocal fold paralysis were compared. RESULTS: A total of 124 patients were recruited. Of those, 17 with no definite identified causes after evaluation and follow-up were assigned to the idiopathic group. The remaining 107 patients with surgery-induced vocal fold paralysis were assigned to the iatrogenic group. Patients in the idiopathic group had higher recruitment of the thyroarytenoid-lateral cricoarytenoid muscle complex and better quality of life compared with the iatrogenic group. CONCLUSION: Idiopathic unilateral vocal fold paralysis has a distinct clinical presentation, with relatively minor denervation changes in the involved laryngeal muscles, and less impact on quality of life compared with iatrogenic vocal fold paralysis. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:E362-E368, 2016.

Office-Based Intracordal Hyaluronate Injections Improve Quality of Life in Thoracic-Surgery-Related Unilateral Vocal Fold Paralysis.

Thoracic-surgery-related unilateral vocal fold paralysis (UVFP) may cause severe morbidity and can cause profound functional impairment and psychosocial stress in patients with pre-existing thoracic diseases. In-office intracordal hyaluronate (HA) injections have recently been applied to improve voice and quality of life in patients with vocal incompetence, but their effect on thoracic-surgery-related UVFP remains inconclusive. We therefore conducted a prospective study to clarify the effect of early HA injection on voice and quality of life in patients with thoracic-surgery-related UVFP. Patients with UVFP within 3 months after thoracic surgery who received office-based HA injection were recruited. Quantitative laryngeal electromyography, videolaryngostroboscopy, voice-related life quality (voice outcome survey), laboratory voice analysis, and health-related quality of life (SF-36) were evaluated at baseline, and at 1 month postinjection. A total of 104 consecutive patients accepted office-based HA intracordal injection during the study period, 34 of whom were treated in relation to thoracic surgery and were eligible for inclusion. Voice-related life quality, voice laboratory analysis, and most generic quality of life domains were significantly improved at 1 month after in-office HA intracordal injection. No HA-related complications were reported. Single office-based HA intracordal injection is a safe and effective treatment for thoracic-surgery-related UVFP, resulting in immediate improvements in patient quality of life, voice quality, and swallowing ability.

Sonographic features of soft tissue tumors in the hand and forearm.

BACKGROUND: High-resolution sonography is well suited for screening soft tissue masses because of its safety, low cost, and real-time, dynamic imaging. The purpose of our study was to elaborate the preoperative sonographic features of soft tissue tumors of the hand and forearm and the corresponding histologic results. METHODS: Thirty-one soft tissue tumors of the hand and forearm were evaluated by ultrasound preoperatively. The mobility, consistency, echogenicity, margin, and color Doppler signal of each tumor were assessed. Dynamic study was also performed. The pathologic diagnosis was obtained after subsequent surgery. RESULTS: The pathologic diagnoses of these soft tissue lesions were lipoma (n = 6), ganglion cyst (n = 6), neurilemmoma (n = 3), neurofibroma (n = 3), giant cell tumor (n = 10), tenosynovitis (n = 2), and malignant lymphoma (n = 1). An adjacent tendon or communication duct extending to the joint space could be found in most giant cell tumors and ganglion cysts; a traceable nerve could be found in most nerve sheath tumors. All benign tumors appeared well-defined. The only malignant tumor appeared ill-defined without a color Doppler signal. CONCLUSION: Sonography enables a reliable diagnosis of the cystic or solid nature of soft-tissue lesions, accurate estimation of the volume, and precise three-dimensional localization of the abnormality. Examiners should perform a dynamic examination and trace the adjacent structure to obtain more diagnostic clues.