Superomedial submucosal partial arytenoidectomy for improved posterior glottic closure: surgical technique and case presentation.

OBJECTIVE: Endoscopic medial partial arytenoidectomy has been described previously for expansion of the posterior glottic airway in bilateral vocal fold paralysis. Superomedial submucosal partial arytenoidectomy (SSPA), a modification of this technique, can improve glottic closure in the setting of an obstructing anteromedially prolapsed arytenoid. We present our surgical technique and a case example. METHODS AND RESULTS: A 45-year-old man presented with dysphonia attributable to unilateral true vocal fold paralysis. Laryngoscopy revealed right true vocal fold atrophy and an anteriorly prolapsed right arytenoid cartilage preventing posterior glottic closure during adduction. Right SSPA and ipsilateral vocal fold injection augmentation were performed without complication. One-month and 11-month postoperative evaluations showed marked improvement in voice, with complete glottic closure. Quality-of-life assessment and patient report showed a durable result at 50 months. CONCLUSION: SSPA may be a valuable technique in the management of breathy dysphonia associated with posterior glottic gap and other sequelae of the malpositioned arytenoid.

Pyriform sinus mucosa stabilization for prevention of postoperative airway obstruction in arytenoid adduction.

OBJECTIVES: The Isshiki arytenoid adduction procedure directly closes the open posterior glottis. Postoperative airway obstruction that necessitates emergent tracheotomy is an important complication in arytenoid adduction patients when the standard posterior thyroplasty window is used to approach the posterolateral larynx. Immediate postoperative fiberoptic laryngoscopy shows ipsilateral edema and/or hematoma of the arytenoid and supraglottic mucosa, with occasional obstructing inspiratory collapse. In this study, I sought to modify the posterior window approach during arytenoid adduction surgery, and thereby decrease the incidence of immediate postoperative airway obstruction. METHODS: I performed a retrospective chart review of 246 arytenoid adduction patients, looking for immediate postoperative airway compromise. RESULTS: There were no episodes of postoperative airway obstruction that necessitated tracheotomy in the first 30 patients in whom I approached the posterolateral larynx using the classic Isshiki techniques. Nine of the succeeding 132 adduction patients required emergent tracheotomy when the standard posterior window technique was used instead of a classic Isshiki approach (6.8%). In the most recent 84 patients, I used one tacking suture to stabilize the elevated pyriform sinus mucosa to the upper margin of the posterior window cartilage at closure. Four of the 84 patients had audible postoperative airway turbulence that abated with medical treatment, and 1 patient required an emergent tracheotomy (1.2%; p = .0495). CONCLUSIONS: Suture stabilization of the pyriform sinus mucosa is effective and is recommended for prevention of posterior glottic airway obstruction after arytenoid adduction when the posterior window technique is used.

Thyroplasty in the previously irradiated neck: A case series and short-term outcomes.

OBJECTIVES/HYPOTHESIS: External beam radiation to the neck is widely considered a contraindication for thyroplasty due to concern for infection and implant extrusion. We present a case series of our experience regarding thyroplasty performed in a previously radiated field. STUDY DESIGN: Retrospective case study at a tertiary academic referral center. METHODS: Using the institution's clinical notes search tool, records from 1999 through 2014 documenting thyroplasty and radiation were identified and reviewed. Patients who received external beam radiation to the operative field prior to thyroplasty were included. Data including duration of radiation, timing and specifics of thyroplasty, postoperative complications, risk factors, clinical voice outcomes, and length of follow-up were collected. RESULTS: Fourteen patients met criteria for the study. Of all thyroplasty performed, 11 were Silastic implants, two were Gore-Tex implants, six had concurrent arytenoid adduction, and one was a midline type II thyroplasty. In terms of risk factors for postoperative complications, two were diabetic, none were active smokers, and one had a splenectomy. All patients were given postoperative antibiotics. The median duration of follow-up after surgery was 14.2 months. No patients were found to have postoperative complications. Pre- and postoperative voice data were assessed. Overall, there was improvement in voice outcomes. CONCLUSIONS: Thyroplasty may be an option for patients who have previously undergone external beam radiation. Short-term and intermediate outcomes in our patients showed no postoperative complications, and generally voice or dysphagia improved. Careful selection is still warranted when considering thyroplasty in a previously irradiated neck, and long-term outcomes need further study. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:1849-1853, 2016.

Swallow function in patients before and after intra-arterial chemoradiation.

OBJECTIVES/HYPOTHESIS: To prospectively evaluate swallow function in patients with advanced head and neck cancer before and after completion of intra-arterial chemoradiation therapy and planned neck dissection. STUDY DESIGN: Prospective nonrandomized study. METHODS Swallow function was evaluated in 11 patients with resectable T4 and selected T3 head and neck cancer before and, on average, 19 weeks after completion of treatment. RESULTS: The Performance Status Scale demonstrated worse scores for both eating in public (P =.004) and normalcy of diet (P =.004) after treatment. Patients who underwent neck dissections had significantly worse scores (P =.02) in normalcy of diet. A significant decline was noted in swallowing functional measures at the time of the repeat evaluation (P =.02). Videofluoroscopic swallow studies revealed altered swallow function in 9 of 11 patients before treatment, with aspiration seen in 3 patients. Following treatment, the incidence of aspiration increased to seven patients. Tongue base retraction, reduced laryngeal elevation, and increased laryngeal vestibule penetration of thick liquid were all statistically significantly worse after treatment. The overall score on the quality of life instrument was not significantly changed from before to after treatment. CONCLUSIONS: The majority of patients demonstrated significantly worse swallow function on all three methods of analysis at 19 weeks after completion of treatment. Continued detailed monitoring of patients' swallow function is critical in determining long-term effects of intra-arterial chemoradiation therapy and neck dissection.

Correlation of the Voice Handicap Index-10 (VHI-10) and Voice-Related Quality of Life (V-RQOL) in patients with dysphonia.

OBJECTIVES: This study examines the correlation between two voice-specific patient-reported outcome measures: the Voice Handicap Index-10 (VHI-10) and Voice-Related Quality of Life (V-RQOL). STUDY DESIGN: Retrospective chart review. PARTICIPANTS: Eight hundred four patients presenting to our voice clinic between May 2009 and August 2011. All patients completed the VHI-10 and V-RQOL in a single sitting. METHODS: Correlation between the two scales was examined using Spearman rank analysis. Calculated VHI-10 score was derived from V-RQOL score by direct conversion equation and compared with measured VHI-10 score. Receiver Operating Characteristic (ROC) curves were derived for diagnostic groups. RESULTS: Spearman correlation coefficient between the VHI-10 and V-RQOL was -0.91 (P < 0.0001). VHI-10 and V-RQOL scores were also significantly correlated among diagnostic categories. Calculated and measured VHI-10 scores were significantly different both for individuals and overall. Area under the curve (AUC) values from ROC curves were significantly different for the presbyphonia (V-RQOL AUC = 0.586 [standard error, SE ± 0.033]; VHI-10 AUC = 0.530 [SE ± 0.031]; P = 0.0014) and muscle tension dysphonia (V-RQOL AUC = 0.536 [SE ± 0.026]; VHI-10 AUC = 0.508 [SE ± 0.26]; P = 0.018) groups, with the V-RQOL showing relatively greater sensitivity. CONCLUSIONS: The VHI-10 and V-RQOL are highly correlated. However, VHI-10 score cannot be calculated from V-RQOL score using the tested equation. The V-RQOL may be more sensitive than the VHI-10 in detecting the impact of presbyphonia and muscle tension dysphonia.

Differences in botulinum toxin dosing between patients with adductor spasmodic dysphonia and essential voice tremor.

OBJECTIVES: To explore possible dose differences in average botulinum toxin (BTX) given to patients with adductor spasmodic dysphonia (ADSD) compared with patients with essential voice tremor (EVT). METHODS: A retrospective study compared the average BTX dose injected in equal doses to the thyroarytenoid (TA) muscles of 51 patients with ADSD with 52 patients with EVT. RESULTS: Those with ADSD received significantly higher total doses (6.80 ± 2.79 units) compared with those with EVT (5.02 ± 1.65 units). Dose at time of first injection, age at time of first injection, gender, year of first injection, and average time between injections were included in multivariate analysis but did not interact with total average dose findings. CONCLUSIONS: Patients with ADSD may need relatively higher doses of BTX injections to bilateral TA muscles compared with patients with EVT.