Reduction in Short- and Long-term Pneumonia Rate With Laryngoplasty for Unilateral Vocal Fold Paralysis.

OBJECTIVE: To examine the association of laryngoplasty, voice therapy, and pneumonia rate in patients with unilateral vocal fold paralysis (UVFP). STUDY DESIGN: Population-based retrospective cohort study. SETTING: Data were collected from the LHID2000 (Longitudinal Health Insurance Database 2000), containing the information of 1 million randomly selected patients in Taiwan. METHODS: In the LHID2000, we identified 439 patients having new diagnoses of UVFP from 1997 to 2013. We grouped the aforementioned patients according to UVFP treatment and probed the occurrence of pneumonia: 305 patients underwent laryngoplasty or voice therapy, and 134 patients did not undergo treatment. Follow-up procedures were executed for the enrollees until death or December 31, 2013, representing the end of the study period. We assessed the association of UVFP treatment and pneumonia by executing Cox proportional hazards regression. RESULTS: The pneumonia cumulative incidence was significantly higher among enrolled patients without treatment than in those receiving treatment (P < .001). The pneumonia incidence was significantly lower in patients receiving UVFP treatment (hazard ratio, 0.49; 95% CI, 0.27-0.88; P = .018), as validated by the Cox proportional hazards model after adjustment. Patients undergoing laryngoplasty with or without voice therapy had a significantly lower incidence of pneumonia at 6 months and 1, 3, and 5 years, whereas those undergoing voice therapy alone did not. CONCLUSION: Laryngoplasty was associated with a lower incidence of short- and long-term pneumonia in patients with UVFP. Physicians should encourage patients with UVFP at risk of aspiration to receive prompt evaluation as well as treatment.

Unilateral Vocal Fold Paralysis and Voice Therapy: Does Age Matter? A Prospective Study With 100 Consecutive Patients.

OBJECTIVE: To use a multidimensional assessment to analyze potential influence of "aging" in the functional outcomes achieved by a group of patients with recent onset of unilateral vocal fold paralysis (UVFP) who underwent voice therapy. DESIGN: Prospective, observational, and cross-sectional study. SETTING: Otolaryngology department, Centro Hospitalar do Porto. PARTICIPANTS: Patients with UVFP who underwent voice therapy. MAIN OUTCOME MEASURES: Data regarding gender, age, side and position of the paralyzed vocal fold, etiology, comorbidities, and Voice Handicap Index (VHI)-30 questions, before and after voice therapy, were collected. Glottal insufficiency was also evaluated, by endoscopic laryngoscopy, before and after voice therapy. RESULTS: A total of 100 patients (76 females and 24 males) with UVFP were included. Mean age was 61.04 years (range: 21-88 years). The mean score of VHI, before and after voice therapy, was statistically different (P < .001) with a lower score after therapy. The score of VHI was not influenced by age (P = .717). However, for each 10-year increase in age, the score of VHI, before and after voice therapy, increased 1.91 and 2.86 units, respectively. As concerns endoscopic findings, 80% of patients exhibited better glottis closure after voice therapy (P < .001), and this was not influenced by age. Nevertheless, for each 10-year increase in age, the chance of endoscopic improvement reduced 3%. CONCLUSIONS: A clear and significant improvement was visible in the endoscopic and self-assessment ratings after rehabilitation by isolated voice therapy. Despite possible anatomical and physiological aging changes in the phonatory system, age did not compromise the successful rate obtained by voice therapy.

Rehabilitation Protocol for Unilateral Laryngeal and Lingual Paralysis (Tapia Syndrome): Comment About "A Challenging Case of Tapia Syndrome After Total Thyroidectomy" By Ildem Deveci, Mehmet Surmeli, and Reyhan Surmeli.

Tapia syndrome is a rare complication after surgery, with ipsilateral paralysis of vocal cord and tongue due to extracranial involvement of recurrent laryngeal and hypoglossal nerves. Tapia's case report is extremely interesting for both the rarity of the reported cases and for the importance of an early rehabilitation. In a previous work, we reported a case of Tapia syndrome after cardiac surgery for aortic aneurysm, and the protocol of logopedic rehabilitation adopted. In the postoperative period, he developed severe dyspnea and dysphagia that required a tracheostomy and a logopedic rehabilitation therapy that led to a fast and efficient swallowing without aspiration after 47 sessions (less than 4 months). The progressive recovery of the function suggests aprassic nerve damage. However, the logopedic therapy is recommended to limit the possibility of permanent functional deficits and quickly recover swallowing and phonation.

Rehabilitation Therapy for Vocal Fold Paralysis Caused by Lung Cancer: A Case Report.

OBJECTIVE: Unilateral vocal fold paralysis (UVFP) can be caused by iatrogenic injury or tumor-induced damage to the recurrent laryngeal nerve. Studies of comprehensive rehabilitation therapies for patients suffering from severe UVFP are limited. The purpose of this case report is to describe an improvement in complete aphonia after comprehensive rehabilitation therapies in a patient with severe UVFP due to a lung tumor. METHODS: An 81-year-old woman with a history of bronchial adenoma had complete aphonia due to compression of the left recurrent laryngeal nerve by the tumor. Dynamic fibrolaryngoscope revealed paralysis of the left vocal fold. The patient was treated with interferential current therapy, vocal training, and kinesiology taping. Indicators of voice recovery were scored according to the grade, roughness, breathiness, asthenia, strain scale, and the voice handicap index. RESULTS: After 10 days of comprehensive rehabilitation treatment, the patient recovered from complete aphonia to normal communication. The hoarseness and breathiness of patient were significantly improved. In addition, the grade, roughness, breathiness, asthenia, strain, and the voice handicap index scores changed from severe to mild or absent. CONCLUSION: This case provided a novel comprehensive treatment for a patient with UVFP, which was safe, cost-effective, and easy to implement in clinic.

Is a voice-specific instrument more indicative of stroboscopy results than common clinical queries?

OBJECTIVES: To determine whether the Voice Handicap Index-10 (VHI-10) predicts diagnoses made via laryngoscopy/stroboscopy, as compared to common clinical inquiries about vocal characteristics. METHODS: We prospectively collected data from a cohort of 204 consecutive patients newly presenting for ambulatory laryngology evaluation. Each patient completed the VHI-10 and 16 concurrent mainstream queries about vocal characteristics such as weakness, breathiness, fatiguability, or inability to shout. Using the objective diagnoses made by laryngoscopy/stroboscopy as a gold standard, the area under the receiver operating characteristic curves (AUC), sensitivity, and specificity were determined. RESULTS: For unilateral vocal fold paralysis, VHI-10 scores had an AUC of 0.78 (95% CI, 0.68-0.88) and had better discrimination than 12 common clinical queries. At a threshold score of ≥11, VHI-10 sensitivity was 0.94; at a threshold of ≥31, specificity was 0.91. For laryngeal stenosis, the VHI-10 score demonstrated moderate discrimination, with an AUC of 0.79 (95% CI, 0.56-1.00) and higher discrimination than three common clinical queries. At a threshold score of ≥11, VHI-10 sensitivity was 1.00; at a threshold of ≥31, specificity was 0.89. Both VHI-10 scores and common clinical queries had low diagnostic ability for vocal fold paresis, laryngopharyngeal reflux (LPR), paradoxical vocal fold motion, and vocal fold scar or atrophy. CONCLUSIONS: The VHI-10 score is an effective diagnostic indicator of laryngoscopy/stroboscopy findings of vocal fold paralysis and laryngeal stenosis, performing better than multiple mainstream queries about vocal characteristics. VHI-10 scores and common clinical queries are limited in their ability to indicate paresis, reflux, paradoxical motion, and vocal fold scar or atrophy. LEVEL OF EVIDENCE: 2c Laryngoscope, 130:992-999, 2020.

Vocal Fold Motion Recovery in Patients With Iatrogenic Unilateral Immobility: Cervical Versus Thoracic Injury.

OBJECTIVES:: Prognostic information about the return of vocal fold mobility in patients with iatrogenic unilateral vocal fold immobility (UVFI) can help with informed decisions about temporary and permanent treatment options. Although many variables can influence the likelihood of recovery, clinical experience suggests that cervical versus thoracic injury is a determining factor. The purpose of this study was to compare recovery rates from UVFI between cervical and thoracic injuries. METHODS:: A retrospective review of the medical record was performed on all adult patients diagnosed with complete iatrogenic UVFI from 2005 to 2015 (n = 923). Patients with incomplete data and etiologies of idiopathic, malignancy, or stenosis were excluded, leaving a study cohort of 502 patients who were categorized as having UVFI after cervical (n = 329) or thoracic (n = 173) injury. Data regarding site of iatrogenic injury (cervical vs thoracic), mobility status, and time interval to recovery or surgical intervention were recorded and compared using χ2 analyses. RESULTS:: Overall, 15% of patients recovered vocal fold mobility at a median of 4.1 months. Patients with cervical injury (65 of 329 [20%]) were significantly more likely to recover mobility than patients with thoracic injury (11 of 173 [6.4%]) (odds ratio, 3.63). The cervical cohort contained more women (68% vs 31%) and was younger (mean age, 60.4 ± 13.8 vs 64.1 ± 16.1 years; Cohen's D = 0.25). CONCLUSIONS:: Patients with cervical injuries resulting in UVFI are 4 times more likely to recover mobility than patients with thoracic injuries. This information can be valuable in counseling patients with UVFI and may affect clinical decision making.

Recurrent laryngeal nerve reinnervation: is this the standard of care for pediatric unilateral vocal cord paralysis?

PURPOSE OF REVIEW: Ansa to recurrent laryngeal nerve reinnervation, otherwise known as a nonselective laryngeal reinnervation (NSLR), is growing in popularity for the management of pediatric unilateral neuronal vocal fold movement impairment (VFMI). In this chapter, we will review the current treatment options for neuronal VFMI and role that NSLR plays in the treatment algorithm. RECENT FINDINGS: In 2018, Bouhabel and Hartnick published a survey of fellowship trained pediatric otolaryngologists and found an increasing comfort level with NSLR. Respondents felt that NSLR resulted in favorable subjective and objective postsurgical voice outcomes. Furthermore, NSLR may decrease the risk of aspiration in children with neuronal VFMI. Although NSLR appears to work, the voice results are not perfect for all children. Further work is being done to understand which preoperative variables, such as age, time from injury, and preop laryngeal electromyography, may predict a better voice outcome. SUMMARY: A variety of treatment options exist for unilateral neuronal VFMI. Recent data and developments demonstrate the effectiveness of reinnervation as a potential first-line surgical intervention in children with unilateral neuronal VFMI.

Comparison of EMG signals recorded by surface electrodes on endotracheal tube and thyroid cartilage during monitored thyroidectomy.

A variety of electromyography (EMG) recording methods were reported during intraoperative neural monitoring (IONM) of recurrent laryngeal nerve (RLN) in thyroid surgery. This study compared two surface recording methods that were obtained by electrodes on endotracheal tube (ET) and thyroid cartilage (TC). This study analyzed 205 RLNs at risk in 110 patients undergoing monitored thyroidectomy. Each patient was intubated with an EMG ET during general anesthesia. A pair of single needle electrode was inserted obliquely into the TC lamina on each side. Standard IONM procedure was routinely followed, and EMG signals recorded by the ET and TC electrodes at each step were compared. In all nerves, evoked laryngeal EMG signals were reliably recorded by the ET and TC electrodes, and showed the same typical waveform and latency. The EMG signals recorded by the TC electrodes showed significantly higher amplitudes and stability compared to those by the ET electrodes. Both recording methods accurately detected 7 partial loss of signal (LOS) and 2 complete LOS events caused by traction stress, but only the ET electrodes falsely detected 3 LOS events caused by ET displacement during surgical manipulation. Two patients with true complete LOS experienced temporary RLN palsy postoperatively. Neither permanent RLN palsy, nor complications from ET or TC electrodes were encountered in this study. Both electrodes are effective and reliable for recording laryngeal EMG signals during monitored thyroidectomy. Compared to ET electrodes, TC electrodes obtain higher and more stable EMG signals as well as fewer false EMG results during IONM.

Early voice rehabilitation with injection laryngoplasty in patients with unilateral vocal cord palsy after thyroidectomy.

Injection laryngoplasty is a safe and efficient procedure for the management of hoarseness resulting from unilateral vocal cord paralysis (VCP). However, proper timing and material of injection after the occurrence of VCP are still under discussion. This study aimed to evaluate the efficacy of early injection laryngoplasty with long-lasting soft tissue filler in patients with post-thyroidectomy unilateral VCP. We retrospectively reviewed the medical records of 59 consecutive patients who developed unilateral VCP after thyroidectomy and received ArteSense™ injection laryngoplasty. Objective and subjective voice outcomes were compared between early (within 3 months) and late (after 3 months) injection groups. The mean duration from thyroidectomy to injection laryngoplasty was 39.7 and 334.2 days in the early and late injection groups, respectively. All of the tested objective and subjective voice parameters were significantly improved in both the early and late groups. However, the amount of voice improvement was significantly larger in the early injection group, especially jitter% (P = 0.02) and shimmer% (P = 0.03) improvement. Four patients showed spontaneous recovery from VCP after early injection laryngoplasty; nevertheless, their voice outcomes were excellent and there was no significant discomfort or complication. Early voice rehabilitation with injection laryngoplasty is a safe and efficient treatment in the patients with post-thyroidectomy unilateral VCP.

Giant cystic schwannoma of the middle mediastinum with cervical extension.

Schwannomas (neurilemmomas) are benign tumors arising from the Schwann cells of the neural sheath. They are typically, well-encapsulated lesions which rarely adhere to the adjacent structures. In the chest, schwannomas are often seen within the posterior mediastinum and commonly originating along intercostal nerves. Several operative approaches have previously been described for the resection of these tumors, including thoracoscopic techniques and posterolateral thoracotomy. We report in this case a giant cystic mediastinal schwannoma of the left recurrent laryngeal nerve with cervical extension, unresectable by the usual described approaches, which was completely removed through a cervical approach.

The cost of vocal fold paralysis after thyroidectomy.

OBJECTIVES/HYPOTHESIS: To determine the added cost of care and analyze risk factors in patients who suffered vocal fold paralysis (VFP) after thyroid surgery. STUDY DESIGN: Retrospective cohort study. METHODS: Seventy-six patients who developed unilateral or bilateral VFP after thyroidectomy from 2005 through 2009, and a control group of 238 patients who underwent the same surgery without developing VFP, were compared on hospital charges, hospital and intensive care unit (ICU) length of stay (LOS), unplanned intubation, tracheotomies, respiratory failure, readmission, death, pathology, body mass index (BMI), gland weight, swallowing studies, and need for indwelling feeding tube. Differences between outcomes for unilateral VFP patients versus bilateral VFP patients were analyzed. Rate of recovery of VFP and need for further surgery after thyroidectomy were described. RESULTS: Patients who developed VFP after thyroidectomy had significantly greater rates of all the parameters listed above. BMI, gland weight, and pathology (malignant vs. benign) were not significantly different between the two groups. VFP group underwent additional surgeries after thyroidectomy related to the VFP. Thirty-three% of unilateral VFP patients with long-term follow-up recovered fully. Patients with bilateral VFP with long-term follow-up, had recovery of one vocal fold in 50% and both in 23% of cases. CONCLUSIONS: Patients with unilateral or bilateral VFP after thyroidectomy experience significantly more morbidity and incurred significantly more health care charges after surgery than similar patients who do not have VFP after thyroidectomy. The likelihood of VFP was not related to malignancy, BMI, or thyroid gland weight in this series.

Update on pediatric voice and airway disorders: assessment and care.

PURPOSE OF REVIEW: To investigate the status of the recent literature focused on studying the assessment and treatment of pediatric voice and airway disorders using both established and novel techniques. RECENT FINDINGS: Recent research regarding voice assessment and treatment reveals the use of systematic and innovative approaches when collecting instrumental and perceptual voice data. There are recent advancements in certain surgical interventions designed to minimize complications. Wider use of functional endoscopic imaging of the pediatric larynx is improving our understanding of childhood voice production and airway management. There is also an important emerging focus on quantifying the impact of having a childhood voice disorder through the use of new tools. Although there is an increase in pediatric voice and airway research, many studies tend to be entirely descriptive rather than quantitative. There continues to be little specific research that uses prospective, longer-term and formal voice outcomes before and after behavioral and surgical interventions. SUMMARY: Pediatric voice and airway disorders are an important childhood health problem. Voice assessment in children should include formal perceptual and instrumental evaluations, including sophisticated acoustic, aerodynamic and imaging modalities. The care of these children requires a collaborative approach that includes systematic and innovative treatment methods.

Transferable skills in the field of speech language pathology.

PURPOSE: To highlight new knowledge and technologies that support the transfer of skills generally acquired by speech language pathologists (SLPs) in academic training programs and clinical practice to involvement in the evaluation and management of individuals with disorders such as paradoxical vocal fold movement (PVFM), chronic cough, manifestations of extra-esophageal reflux (EER), esophageal dysphagia and rumination disorder. RECENT FINDINGS: A range of studies published in the previous year provide data to support SLP involvement in the management of some disorders, including PVFM, chronic cough, and some manifestations of EER, both as providers and as clinical resources for other health professionals. However, little research is available that describes the role of SLPs in management of esophageal dysphagia or rumination disorder. SUMMARY: Recent research supports the expanded role of the SLP in the interdisciplinary management of PVFM, chronic cough, manifestations of EER, esophageal dysphagia, and rumination. SLP and other health professionals involved in the care of these patients must find a balance between the practical challenges of treating individuals with increasingly complex medical issues and staying abreast of the latest developments in the diagnosis and treatment of these disorders.

Laryngeal pacing for bilateral vocal fold immobility.

PURPOSE OF REVIEW: This article reviews literature on the scientific background of functional electric stimulation of the immobile larynx, the status of animal pacing trials, and first clinical attempts to establish laryngeal pacing. RECENT FINDINGS: Impaired vocal fold motion is seen following recurrent laryngeal nerve paralysis and is a result of inadequate or synkinetic reinnervation. The term vocal fold paralysis should only be used after verification using laryngeal electromyography. A variety of animal trials give clear evidence supporting the feasibility of laryngeal pacing as a new dynamic approach for the rehabilitation of patients with bilateral vocal fold motion impairment. Laryngeal pacing has become clinically applicable with minimal invasive electrode insertion and newly designed stimulation circuits. SUMMARY: Laryngeal pacing seems to be on the right path to open up a dynamic rehabilitation of the bilaterally motion-impaired larynx.

Cricothyroid approximation for voice and swallowing rehabilitation of high vagal paralysis secondary to skull base neoplasms.

This study documents the speech and swallowing outcomes of isolated ipsilateral cricothyroid approximation (aka tensioning thyroplasty; Type IV thyroplasty) for the treatment of high vagal paralysis (combined superior laryngeal nerve and recurrent laryngeal nerve paralysis). This is a pilot study of five cases with high vagal paralysis consequent to skull base neoplasms. Unilateral cricothyroid tensioning sutures were used. In all cases, vocal fold tensioning and vertical realignment of lax vocal folds were achieved. A partial, but acceptable medialization of vocal cord position was achieved. In all cases, aspiration was minimized and normal swallow function was restored by 6 weeks. The voice outcome was excellent in four cases and acceptable in one. Cricothyroid approximation restores vocal fold tension; in addition, it restores vertical vocal fold position and partially restores horizontal vocal fold position. Good voice and swallowing outcomes have been achieved. The procedure is quick, safe, and convenient when combined with a skull-base excision procedure. Further evaluation is merited.

Preliminary investigation of adjustable balloon implant for type I thyroplasty.

OBJECTIVE: We present the adjustable balloon implant (ABI), a novel implant to be used in type I thyroplasty for the treatment of vocal fold paralysis. The ABI offers the same medialization provided by other implants, but can easily be catered to individual patient anatomy as well as modified postoperatively without the need for a revision thyroplasty. STUDY DESIGN: Repeated measures with each larynx serving as its own control. METHODS: Medialization thyroplasty (MT) with the ABI was performed on five excised canine larynges. Mucosal wave, aerodynamic, and acoustic parameters were measured for three conditions: normal; right vocal fold paralysis; and paralysis with the ABI. RESULTS: Insertion of the ABI resulted in significant decreases in both phonation threshold pressure and phonation threshold flow. Perturbation parameters of percent jitter and percent shimmer were also significantly decreased and restored to normal levels. Signal-to-noise ratio was significantly increased to the normal level as well. The mucosal wave was preserved after implant insertion. CONCLUSIONS: This preliminary experiment showing significant improvements in aerodynamic and acoustic parameters demonstrates the potential of the ABI as a thyroplasty implant. Effective medialization and preservation of the mucosal wave combined with postoperative adjustability makes it a potentially valuable clinical device.

Voice therapy for laryngeal hemiplegia: the role of timing of initiation of therapy.

OBJECTIVE: Laryngeal hemiplegia, also known as vocal fold paralysis, causes severe communicative disability. Although voice therapy is commonly considered to be beneficial for improving the voice quality in several voice disorders, there are only a few papers that present scientific evidence of the effectiveness of voice therapy in treating the disabilities of laryngeal hemiplegia. The aim of this study was to evaluate the outcomes of voice therapy in patients with laryngeal hemiplegia and to evaluate the role of the time gap between onset of laryngeal hemiplegia and initiation of therapy. DESIGN: A prospective study comparing subjects treated either within or more than 3 months after the onset of laryngeal hemiplegia. SUBJECTS: The study involved 30 laryngeal patients with hemiplegia (16 males, 14 females, age range 15-80 years). METHODS: All patients underwent videolaryngostroboscopy, maximum phonation time measurement, GIRBAS perceptual evaluation, Voice Handicap Index self-assessment and Multi-Dimensional Voice Program voice analysis before and after therapy. RESULTS: In all tests, there were significant improvements in voice quality, both in the group treated within 3 months after the onset of laryngeal hemiplegia and in the group treated after this time. CONCLUSION: Voice therapy is effective in treating laryn-geal hemiplegia even if treatment is delayed by more than 3 months from onset of laryngeal hemiplegia.

Multiparameter comparison of injection laryngoplasty, medialization laryngoplasty, and arytenoid adduction in an excised larynx model.

OBJECTIVES/HYPOTHESIS: Evaluate the effect of injection laryngoplasty (IL), medialization laryngoplasty (ML), and ML combined with arytenoid adduction (ML-AA) on acoustic, aerodynamic, and mucosal wave measurements in an excised larynx setup. STUDY DESIGN: Comparative case study using ex vivo canine larynges. METHODS: Measurements were recorded for eight excised canine larynges with simulated unilateral vocal fold paralysis before and after vocal fold injection with Cymetra. A second set of eight larynges was used to evaluate medialization laryngoplasty using a Silastic implant without and with arytenoid adduction. RESULTS: IL and ML led to comparable decreases in phonation threshold flow (PTF), phonation threshold pressure (PTP), and phonation threshold power (PTW). ML-AA led to significant decreases in PTF (P = .008), PTP (P = .008), and PTW (P = .008). IL and ML led to approximately equal decreases in percent jitter and percent shimmer. ML-AA caused the greatest increase in signal-to-noise ratio. ML-AA discernibly decreased frequency (P = 0.059); a clear trend was not observed for IL or ML. IL significantly reduced mucosal wave amplitude (P = 0.002), whereas both ML and ML-AA increased it. All procedures significantly decreased glottal gap, with the most dramatic effects observed after ML-AA (P = 0.004). CONCLUSIONS: ML-AA led to the greatest improvements in phonatory parameters. IL was comparable to ML aerodynamically and acoustically, but caused detrimental changes to the mucosal wave. Incremental improvements in parameters recorded from the same larynx were observed after ML and ML-AA. To ensure optimal acoustic outcome, the arytenoid must be correctly rotated. This study provides objective support for the combined ML-AA procedure in tolerant patients.

Recovery from neurological sequelae secondary to oncological brain surgery in an adult growth hormone-deficient patient after growth hormone treatment.

OBJECTIVE: To report an unusual case of significant neurological recovery in a 26-year-old growth hormone-deficient female patient with significant neurological sequelae resulting from brain surgery at 11 years of age. DESIGN: Case report. RESULTS: Most of the neurological sequelae present at admission recovered after 8 months of combined growth hormone administration and kinesitherapy/speech therapy. These include an increase in tongue size and mobility and in the amount and quality of saliva, improvement in vocal cords function, recovery of oesophageal peristalsis and disappearance of sleep apnoea. CONCLUSION: Since the patient had undergone intensive physical rehabilitation for a 15-year period with no significant improvement, it is tempting to speculate that the correction of growth hormone deficiency improved her rehabilitation. Therefore, we propose that growth hormone treatment, combined with the adequate kinesitherapy, may be a useful therapy for effective recovery from some neurological deficits in patients with growth hormone deficiency.