Dysphonia and vocal fold telangiectasia in hereditary hemorrhagic telangiectasia.

OBJECTIVE: This case report is the first documentation of dysphonia and vocal fold telangiectasia as a complication of hereditary hemorrhagic telangiectasia (HHT). METHODS: Case report of a 40-year-old man with HHT presenting with 2 years of worsening hoarseness. RESULTS: Hoarseness corresponded with a period of anticoagulation. Endoscopy revealed vocal fold scarring, vocal fold telangiectasias, and plica ventricular is suggestive of previous submucosal vocal fold hemorrhage and subsequent counterproductive compensation with ventricular phonation. CONCLUSION: Hereditary hemorrhagic telangiectasia may present as dysphonia with vocal fold telangiectasias and place patients at risk of vocal fold hemorrhage.

An Exploration of the Risk Factors, Severity, and Sequelae of Vocal Fold Hemorrhage in a Population of Voice Patients Before and After Diagnosis.

BACKGROUND: Vocal fold hemorrhage (VFH) is the rupture (usually acute) of a blood vessel within the true vocal fold. The long-term sequelae of VFH on the mucosal wave (MW) and glottic gap on video stroboscopy remain understudied. The primary objective of this study was to investigate the short-term and long-term consequences of VFH through measured and rated analysis of the mucosal wave and glottic gap. METHODS: The presence of VFH and its extent (limited/moderate vs. extensive VFH) were identified. The primary outcome of this study was mucosal wave, which was assessed on an ordinal scale by three blinded raters pre and posthemorrhage. Only patients who had undergone strobovideolaryngoscopy before sustaining VFH were included. Mucosal wave and glottic gap also were measured using image pixel analysis using the open-access tool, ImageJ (NIH, Bethesda, MD). RESULTS: Twenty-three subjects were included in this study (mean age 39.78 ± 15.54). Intra-rater reliability for MW ratings was 81.48% ± 6.150% (minimum 77.78%) for all evaluators (κ = 0.519 [0.267-0.772], P < 0.001). Inter-rater reliability analysis revealed 75.56% agreement between evaluators (κ = 0.524 [0.425-0.623], P < 0.001). MWMeasured extrapolated from ImageJ methodology correlated significantly with MWRated (n = 70, r = 0.448, P < 0.001). ΔMWMeasured from baseline to follow-up evaluation were compared for both the initial follow-up visit (FU1) and the second follow-up visit (FU2) [-4.135 ± 31.01 vs. 36.50 ± 39.97, P = 0.025]. Hence, ΔMWMeasured was significantly better by FU2 than FU1, with the larger positive change from baseline representing a greater improvement in the measured mucosal wave. Additionally, there were significant differences in ΔMWRated between those with limited/moderate VFH and those with extensive VFH at FU1. Duration of absolute voice rest correlated significantly with time to VFH resolution. Long-term change in mucosal wave after hemorrhage was assessed using both ΔMWMeasured and MWRated. Based on ΔMWRater, 35.0% of subjects demonstrated ongoing and worse mucosal wave restriction compared to baseline at their most recent follow-up visit. Based on ΔMWMeasured, 50.0% of the subjects showed ongoing and worse mucosal wave restriction compared to baseline at their most recent follow-up visit. CONCLUSION: Overall long-term restrictions in MW after hemorrhage were present in 35.0% of the subjects based on ratings and 50.0% of the patients based on the measured MW using ImageJ, demonstrating the importance of ongoing study into this pathology and how to prevent it, especially in PVU and professional singers. Patients presenting with extensive hemorrhage were at risk for more prominent, detectable changes in mucosal wave compared to those with limited/moderate hemorrhage in the short-term, defined by a mean FU time of 3 months, but not long-term, characterized by a mean FU time 6 months or greater. Whether the severity of VFH is a true indicator of mucosal wave alterations requires additional study, as does the reliability and validity of ImageJ mucosal wave and glottic gap measurement techniques.

Prevalence and Long-term Consequences of Vocal Fold Hemorrhage in Patients who Underwent Microscopic Laryngeal Surgery or Type I Thyroplasty.

OBJECTIVE: Examine incidence of postoperative vocal fold (VF) hemorrhage (PVFH) in patients who underwent microscopic laryngeal surgery and type I thyroplasty and determine the long-term consequences of hemorrhage on the outcome of the surgery. STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: Medical records of patients from a quaternary care laryngology practice who underwent microdirect laryngoscopy (MDL) or type I thyroplasty between November 2015 and December 2018 were reviewed as a consecutive sample. MDL procedures not performed on the VF were excluded. Demographic and medical history data associated with risk of bleeding were collected, and records were reviewed for the incidence of PVFH and long-term consequences of PVFH through Voice Handicap Index-10 (VHI-10) and preoperative and postoperative videostroboscopic findings. We considered each VF surgery as one procedure. Statistical analysis was performed using chi-square analysis for categorical data and a student t test for means. A P value of 0.05 or less was considered significant. RESULT: Total 155 patients were enrolled. The patients underwent 182 MDL surgeries, (122 bilateral and 60 unilateral), and 60 Type 1 thyroplasty surgeries (13 bilateral and 47 unilateral). In the MDL group, 34 of 304 procedures (11%) resulted in VFH. In the thyroplasty group, 10 of 73 procedures (13.7%) were associated with PVFH. Bilateral MDL procedures were associated with a higher incidence of PVFH in comparison with unilateral procedures (P= 0.03), but bilateral thyroplasties were not (P= 0.33). None of the demographic factors significantly increased or decreased risk of PVFH. Comparing the difference between preoperative and 3-6 month postoperative VF mucosal function, and preoperative and 3-6 month postoperative VHI-10 in both MDL and thyroplasty groups, no statistically significant difference was found between patients who had experienced PVFH and those who had not. CONCLUSION: This is the largest investigation into the incidence and long-term consequences of the PVFH. 11% of the patients in the MDL group experienced PVFH; the vibratory margin of the VF was involved in only 1.3%.; and 13.7 % of the procedures in the thyroplasty group resulted in PVFH. However, PVFH was not associated with significant increase in VHI-10 or decrease in VF vibratory function during 3-6 month postoperative follow-up visits. The incidence of PVFH was related significantly to postoperative phonotrauma and upper respiratory infection, but not to gender, age, history of smoking and alcohol consumption, pulmonary and cardiovascular comorbidities, or pre-existing VF varicosities or ectasias.

Vocal fold varices and risk of hemorrhage.

OBJECTIVES/HYPOTHESIS: To establish risk of hemorrhage in patients with varices compared to those without, determine additional risk factors, and make evidence-based treatment recommendations. STUDY DESIGN: Retrospective cohort study. METHODS: Patients who were vocal performers presenting for care during a 24-month period were analyzed to determine incidence of hemorrhage. Patients with varices were compared to those without. Demographic information and examination findings (presence, location, character, and size of varices; presence of mucosal lesions or paresis) were analyzed to determine predictors of hemorrhage. RESULTS: A total of 513 patients (60.4% female, mean age 36.6 years ± 13.95 years) were evaluated; 14 patients presenting with hemorrhage were excluded. One hundred and twelve (22.4%) patients had varices; 387 (77.6%) did not. The rate of hemorrhage in patients with varices was 2.68% at 12 months compared to 0.8% in patients without. Cox proportional hazard regression analysis revealed a hazard ratio of 10.1 for patients with varix developing hemorrhage compared to nonvarix patients (P < 0.0001). The incidence rate of hemorrhage was 3.3 cases per 1,000 person-months for varix patients compared to 0.5 cases per 1,000 person-months in the nonvarix group. There was no significant difference in the incidence of paresis, mucosal lesions, location of varix (left or right side; medial or lateral), or varix morphology (pinpoint, linear, lake) between patients who hemorrhaged and those that did not. CONCLUSION: The presence of varices increases the risk of hemorrhage. Varix patients had 10 times the rate of hemorrhage compared to nonvarix patients, although the overall incidence is low. This data may be used to inform treatment of patients with varices. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1163-1168, 2016.