The Long Term Results of Hyaluronic Acid/Dextranomer Injection Laryngoplasty in Unilateral Vocal Fold Paralysis.

OBJECTIVE: This study was conducted to present the long-term functional outcomes of injection laryngoplasty (IL) with hyaluronic acid/dextranomer (HA/D) in unilateral vocal fold paralysis (UVFP). METHODS: A total of 40 patients who underwent HA/D injection for UVFP were enrolled. The acoustic analysis of the voice was evaluated with jitter percentage, shimmer percentage, maximum phonation time, harmonics-to-noise ratio, and fundamental frequency. The psychosocial effect of the voice was determined using the Voice Handicap Index-10. Fiberoptic endoscopic evaluation of swallowing was performed and 2 scales were used for quantification: a modified penetration-aspiration scale and a dysphagia score. All measurements were performed at preoperative day and postoperative months 1, 6, and 24. RESULTS: A statistically significant improvement was observed for all of the evaluated parameters except the maximum phonation time for postoperative months 1, 6, and 24 (P < .05). In the evaluation of the maximum phonation time, although there was a significant improvement for the postoperative months 1 and 6, no significant difference was observed between the postoperative 24th month and the preoperative value. CONCLUSIONS: HA/D injection laryngoplasty is an effective method both in the short- and long-term to improve voice and swallowing functions in patients with UVFP.

Acoustics and aerodynamic effects following glottal and infraglottal medialization in an excised larynx model.

OBJECTIVE: This study aimed to investigate the impact of the implant's vertical location during Type 1 Thyroplasty (T1T) on acoustics and glottal aerodynamics using excised canine larynx model, providing insights into the optimal technique for treating unilateral vocal fold paralysis (UVFP). METHODS: Measurements were conducted in six excised canine larynges using Silastic implants. Two implant locations, glottal and infraglottal, were tested for each larynx at low and high subglottal pressure levels. Acoustic and intraglottal flow velocity field measurements were taken to assess vocal efficiency (VE), cepstral peak prominence (CPP), and the development of intraglottal vortices. RESULTS: The results indicated that the implant's vertical location significantly influenced vocal efficiency (p = 0.045), with the infraglottal implant generally yielding higher VE values. The effect on CPP was not statistically significant (p = 0.234). Intraglottal velocity field measurements demonstrated larger glottal divergence angles and stronger vortices with the infraglottal implant. CONCLUSION: The findings suggest that medializing the paralyzed fold at the infraglottal level rather than the glottal level can lead to improved vocal efficiency. The observed larger divergence angles and stronger intraglottal vortices with infraglottal medialization may enhance voice outcomes in UVFP patients. These findings have important implications for optimizing T1T procedures and improving voice quality in individuals with UVFP. Further research is warranted to validate these results in clinical settings.

Office-based blue laser therapy for vocal fold polyps and Reinke's edema: a case study and review of the literature.

PURPOSE: To report the efficacy of blue laser in the treatment of vocal fold polyps and Reinke's edema in an office setting. METHODS: The medical records and video-recordings of patients who underwent office-based blue laser therapy in a tertiary referral center for vocal fold polyps and/or Reinke's edema were reviewed. The primary outcome measures were the Voice Handicap Index-10 (VHI-10) score and disease regression. Acoustic and aerodynamic parameters were also analyzed. RESULTS: Thirty-five patients (21 with vocal fold polyps and 14 with Reinke's edema) were included and a total of 47 lesions were treated. Out of the 35 patients, 7 patients were lost for follow-up. The mean VHI-10 score dropped significantly after surgery by 17.41 ± 8.67 points (p < 0.001). The endoscopic examinations of 38 lesions were reviewed (17 vocal fold polyps and 21 Reinke's edema) before and up to 6 months after laser therapy. In the subgroup with vocal fold polyps (N = 17), there was complete disease regression in 13 and partial in 4. In the subgroup with Reinke's edema (N = 21), there was complete disease regression in 7 and partial disease regression in 14. For patients with vocal fold polyp, there was a significant decrease in shimmer and a significant increase in maximum phonation time postoperatively. For patients with Reinke's edema, there was a significant decrease in shimmer and noise-to-harmonic ratio following treatment. CONCLUSION: Office-based blue laser therapy is an effective treatment for vocal fold polyps and Reinke's edema leading to complete or partial disease regression. All patients had improvement in voice quality.

Three Episodes of Postanesthesia Paradoxical Vocal Cord Motion Disorder in the Same Patient: A Case Report.

Postanesthesia paradoxical vocal cord motion disorder (PVCMD) is often benign. However, if not recognized, PVCMD can lead to unnecessary treatments. Our patient had 3 different surgeries over a period of 20 months. The first episode of PVCMD occurred after a shoulder surgery, and the patient was reintubated. PVCMD was correctly diagnosed and treated successfully with reassurance after an ulnar nerve decompression. The third episode of PVCMD occurred after a cervical fusion surgery. Prevertebral edema from surgery further compromised the airways. Our case demonstrates the challenges of identifying and managing perioperative PVCMD, especially when surgical complications confound the airway management.

Critical Stenosis Because of Vocal Cord Synechiae in a Child.

Stridor is a clinical sign of an underlying disease and a common reason for pediatric emergency department (PED) consultation. Patients presenting with stridor must be evaluated to determine the origin of this abnormality. We present the case of a 7-year-old female patient who presented to our Pediatric Emergency Department with a history of recurrent episodes of stridor with increasing frequency over the previous 4 years, for this reason she was previously admitted to the pediatric intensive care unit. Findings from the otorhinolaryngologic assessment with flexible fiber-optic endoscopy led to a diagnosis of congenital synechia of the vocal cords. The cervical CT scan evidenced critical stenosis of the airway. An initial cordectomy and placement of a silicone device for fixation were performed. Subsequently, the patient required 6 additional interventions for progressive dilation of the glottic space at the level of the vocal cords and injections of mitomycin C injections (an antineoplastic that inhibits collagen proliferation). This case highlights the importance of additional studies (especially examination of the upper airway) when atypical or recurrent findings are revealed by the clinical history, physical examination, or disease course in patients with croup to prioritize cases severe enough to require pediatric intensive care unit admission.

Exploring the anti-inflammatory potential of topical hyaluronic acid for vocal fold injury in a rat model.

PURPOSE: Vocal fold injuries are associated with fibrosis and dysphonia, which is a major obstacle to surgical treatment. The aim of this study is to evaluate the effect of topical hyaluronic acid with or without diclofenac on the inflammatory phase of vocal fold wound healing. METHODS: Forty-one male Sprague-Dawley rats were randomly assigned to four groups: an uninjured control group, an injured control group without any treatment, and two intervention groups in which hyaluronic acid with or without diclofenac was applied to the injured vocal fold. Gene expression of inflammatory markers and ECM-related molecules were examined. RESULTS: Vocal fold injury resulted in a significant upregulation of inflammatory parameters [Ptgs2, Il1b and Il10] and Has1. Tgfb1, Has3 and Eln gene expression were significantly downregulated by the topical application of hyaluronic acid. The combination of hyaluronic acid and diclofenac did not result in any significant changes. CONCLUSIONS: Vocal fold wound healing was significantly improved by a single post-operative topical application of hyaluronic acid. The addition of diclofenac may provide no additional benefit.

Management of Implant Extrusion following Thyroplasty for Vocal Fold Paralysis: A Case Report.

The most widely used laryngeal surgery technique for patients with vocal fold paralysis is medialization thyroplasty. Materials such as Gore-Tex, silastic, and hydroxyapatite are often used, and the most worrisome possible complication is extrusion of the implant. A 36-year-old female patient with a history of pediatric cardiac surgery was diagnosed with left vocal cord paralysis after an episode of upper respiratory infection with a working diagnosis of subclinical left vocal cord paralysis following cardiac surgery. She underwent medialization thyroplasty with a Gore-Tex implant under local anesthesia. On the 21st postoperative day, she presented with sudden-onset hoarseness and dysphagia due to Gore-Tex implant extrusion. The implant was removed and augmentation of the left vocal cord with adipose tissue was performed. Only 14 cases of Gore-Tex implant extrusion have been described in the literature so far. The aim of this case report was not only to show one possible complication when using a Gore-Tex implant but also to present fat augmentation as one of the solutions for revision medialization and salvage treatment, with sustained long-term results.

Endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis using radiofrequency versus coblation.

PURPOSE: To assess the outcomes of endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis (BAVFP) using radiofrequency versus coblation. METHODS: This was a randomized prospective cohort study that carried out on 40 patients with BAVFP who were subjected to endoscopic/assisted microscopic posterior cordotomy. The patients were randomly allocated into two groups: group (A) patients were operated with radiofrequency, and group (B) patients were operated with coblation. Glottic chink, grade of dyspnea, voice handicap index 10 (VHI10), and aspiration were evaluated pre-operatively and 2 weeks and 3 months post-operatively. RESULTS: There was a significant improvement in the glottic chink and VHI10 scores postoperatively with a non-significant difference between both groups regarding the degree of improvement. In addition, there was a significant improvement of the grade of dyspnea with a non-significant impact on the degree of aspiration in both groups post operatively. There was a lower incidence of oedema and granulation formation in the coblation group but without a statistical significance. CONCLUSION: Both techniques are effective alternatives for performing posterior transverse cordotomy in cases of BAVFP.

Changes in vocal fold gene expression and histology after injection augmentation in a recurrent laryngeal nerve injury model.

OBJECTIVE: To investigate changes in neuroregenerative pathways with vocal fold denervation in response to vocal fold augmentation. METHODS: Eighteen Yorkshire crossbreed swine underwent left recurrent laryngeal nerve transection, followed by observation or augmentation with carboxymethylcellulose or calcium hydroxyapatite at two weeks. Polymerase chain reaction expression of genes regulating muscle growth (MyoD1, MyoG and FoxO1) and atrophy (FBXO32) were analysed at 4 and 12 weeks post-injection. Thyroarytenoid neuromuscular junction density was quantified using immunohistochemistry. RESULTS: Denervated vocal folds demonstrated reduced expression of MyoD1, MyoG, FoxO1 and FBXO32, but overexpression after augmentation. Healthy vocal folds showed increased early and late MyoD1, MyoG, FoxO1 and FBXO32 expression in all animals. Neuromuscular junction density had a slower decline in augmented compared to untreated denervated vocal folds, and was significantly reduced in healthy vocal folds contralateral to augmentation. CONCLUSION: Injection augmentation may slow neuromuscular degeneration pathways in denervated vocal folds and reduce compensatory remodelling in contralateral healthy vocal folds.

Treatment efficacy of 532-nm diode laser glottoplasty in patients with sulcus vocalis: a prospective study.

PURPOSE: This study prospectively assessed the efficacy and safety of 532-nm diode laser glottoplasty in patients with sulcus vocalis. METHODS: A prospective human trial was performed from August 2016 to September 2021. 532-nm diode laser glottoplasty was performed in 30 consecutive patients with sulcus vocalis who suffered from voice problems. Patients underwent acoustic aerodynamic, perceptual, stroboscopic, and Voice Handicap Index-10 (VHI-10) evaluations before and 1, 6, and 12 months after laser glottoplasty. RESULTS: Most subjective parameters showed significant improvement (P < 0.05) at 6 months after laser glottoplasty and remained stable at 12 months. Most objective parameters showed significant improvement (P < 0.05) at 12 months after laser glottoplasty. Complications during follow-up included mild vocal fold vibration reduction in 3.3% of patients (1/30) and persistent vocal fold edema in 3.3% of patients (1/30). CONCLUSIONS: Statistically significant voice improvement at 12 months after 532-nm diode laser glottoplasty was achieved without serious complications.

De Novo Granuloma of the Membranous Vocal Fold: A Marker of Occult Malignancy.

OBJECTIVE: De novo occurrence of granuloma (granulation tissue) on the membranous vocal fold is not readily explained by usual causes of granuloma at the vocal process. We describe a series of patients. STUDY DESIGN: Case series. SETTING: Single academic institution. METHODS: Cases were identified over a 16-year period. All patients exhibited granulation tissue on pathology. Demographic details, presentation, treatment, histology, and clinical outcomes were recorded. RESULTS: Five patients (mean age: 74.0 ± 6.1 years, 40.0% male, 40.0% former smokers) underwent a biopsy. Persistent or recurrent granulation led to a second biopsy in 4 patients an average of 1423.5 days later, revealing a new diagnosis of squamous cell carcinoma (SCC) in situ in one and mild dysplasia in another. Further persistence or recurrence led to a third biopsy or excision an average of 302.3 days later in 3 patients, demonstrating SCC in situ in 1. An average of 2.5 biopsies were required with a mean time to SCC in situ diagnosis of 919.5 days from presentation. Two patients continued to demonstrate persistent granulation tissue on histology. CONCLUSION: The membranous vocal fold is an atypical location for granuloma and portends a risk of occult malignancy. The occurrence of de novo granuloma at this site should prompt close long-term clinical surveillance with a low threshold for biopsy. Consideration should be given to tissue collection in the operating room to adequately sample the lesion's base. Concern should persist even after a negative biopsy, and serial observation with repeat biopsy as needed should be pursued.

Quantitative Evaluation of Vocal Bowing Following Bilateral Thyroplasty in Age-Related Vocal Atrophy.

OBJECTIVE: Age-related vocal atrophy (ARVA) is associated with vocal fold bowing, persistent glottal gap during phonation, and dysphonia. Bilateral medialization thyroplasty is sometimes performed in patients with ARVA to improve vocal fold closure and voice. We set out to quantify stroboscopic changes in vocal fold bowing, glottal closure, and abduction angle following bilateral thyroplasty and determine how these changes affect voice quality among patients with ARVA. METHODS: Fifteen individuals with ARVA who underwent bilateral medialization thyroplasty were included in this study. Two independent investigators calculated bowing index (BI), normalized glottal gap area (NGGA), and maximum abduction angle from laryngostroboscopic exams using ImageJ™. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and patient-reported measures were collected before and after thyroplasty. RESULTS: Thyroplasty resulted in a 10-point improvement in overall CAPE-V (Mean dif -10; 95% CI -17, -3.3, p < 0.01) and VHI-10 (mean dif -3.8; 95% CI -9.8, 2.3, p = 0.19, n = 8). NGGA and BI significantly decreased following surgery (mean dif -78; 95% CI -155, -1.5, p = 0.05; and mean dif -2.1; 95% CI -2.4, -0.84, p < 0.01, respectively). BI correlated with CAPE-V scores (r = 0.66, 95% CI 0.22, 0.87, p < 0.01). When considering the normalized combined contributions of both NGGA and BI, there was a stronger correlation in CAPE-V scores (r = 0.87, 95% CI 0.50, 0.97, p < 0.01) compared with either measure alone. CONCLUSIONS: Thyroplasty resulted in a decrease in vocal fold bowing, glottal gap area, and CAPE-V scores in patients with ARVA. Correction of vocal bowing and glottal gap, following bilateral thyroplasty, improved voice measures following surgery. Quantitative evaluation of vocal fold morphology may be valuable when assessing the severity and treatment-response in patients with ARVA following bilateral thyroplasty. Laryngoscope, 134:835-841, 2024.

Enhanced Abductor Function in Bilateral Vocal Fold Paralysis with Muscle Stem Cells.

INTRODUCTION: Patients with bilateral vocal fold paralysis (BVFP) experience airway obstruction because of loss of abductor function of posterior cricoarytenoid (PCA) muscles. We previously reported that implantation of autologous muscle progenitor (stem) cells into thyroarytenoid muscles during reinnervation resulted in improved adductor function. In this study, that same approach was applied to treating PCA muscles in a canine model of BVFP. DESIGN: Animal study. METHODS: Two canines underwent baseline measures of glottal resistance (GR), then complete transection and suture repair of both recurrent laryngeal nerves. Muscle stem cells were isolated from skeletal muscle and cultured. Two months later, GR was measured, and then 107 stem cells were implanted into one PCA muscle of each animal. After four more months, GR and glottal opening force (GOF) were measured and the muscles were harvested for histologic study. One control dog underwent the same procedures without stem cell implantation, for comparison. RESULTS: GR increased by 21%-25% over baseline at 2 months, but after stem cell implantation, improved to 10%-14% over baseline at 6 months. PCA muscle strength, as determined by GOF, was 61%-65% on control sides (no stem cells), and 78%-83% on treated sides (with stem cells). Histology confirmed survival of stem cells and a 50% higher rate of innervation of motor endplates in the stem cell treated sides. CONCLUSION: Autologous muscle progenitor (stem) cells show promise as a potential new therapy for patients with bilateral vocal fold paralysis. Additional studies are needed to determine the optimal number of cells, timing of implantation, and other variables before launching a clinical trial. LEVEL OF EVIDENCE: NA (animal study) Laryngoscope, 134:324-328, 2024.

Return to Vocal Performance Following Microlaryngoscopy in Singers.

INTRODUCTION: Although microlaryngoscopy has been recognized to be effective in addressing lesions in vocal performers, no detailed information regarding return to performance (RTP) following surgery exists. We describe our experience and offer proposals to establish standardized criteria for RTP among vocal performers. METHODS: Records for adult vocalists who underwent microlaryngoscopy for benign vocal fold (VF) lesions and had a clearly documented RTP date between 2006 and 2022 were reviewed. Patient demographics, diagnoses, interventions, and postsurgical care before and after RTP were described. The need for medical and procedural interventions and rate of reinjury were used to determine the success of RTP. RESULTS: Sixty-nine vocal performers (average age: 32.8 years, 41 [59.4%] female, 61 [88.4%] musical theater) underwent surgery for 37 (53.6%) pseudocysts, 25 (36.2%) polyps, 5 (7.2%) cysts, 1 (1.4%) varix, and 1 (1.4%) mucosal bridge. Fifty-seven (82.6%) underwent voice therapy. The average time to RTP was 65.0 ± 29.8 days. Prior to RTP, six (8.7%) experienced VF edema requiring oral steroids and one (1.4%) underwent a VF steroid injection. Within 6 months following RTP, eight (11.6%) received oral steroids for edema and three underwent procedural interventions (two steroid injections for edema/stiffness, one injection augmentation for paresis). One patient experienced pseudocyst recurrence. CONCLUSIONS: Return to vocal performance at an average of 2 months following microlaryngoscopy for benign lesions appears overwhelmingly successful, with low rates of need for additional intervention. There is a need for validated instruments to better measure performance fitness to refine and possibly accelerate RTP. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:329-334, 2024.

Patient Experience With Absolute Voice Rest Following Phonomicrosurgery: A Qualitative Study.

OBJECTIVE(S): Voice rest is commonly recommended following phonomicrosurgery to minimize vocal fold scarring, but associated quality of life (QoL) is low resulting in poor compliance. This study aimed to explore patients' experiences with voice rest following phonomicrosurgery to identify facilitators and barriers. METHODS: This qualitative study used prospective, typical case technique for purposive sampling of consecutive patients who underwent voice rest following phonomicrosurgery for benign vocal fold lesions. Participants were enrolled at a single tertiary Laryngology center located at Unity Health Toronto - St. Michael's Hospital from 2020 to 2022. Semi-structured virtual interviews were conducted 4 weeks following patients' surgery. All interview transcripts were transcribed verbatim and underwent thematic analysis. Participant recruitment was stopped once thematic saturation was achieved. RESULTS: Twenty participants were recruited and 4 withdrew due to scheduling conflicts. Sixteen participants completed interviews, all of whom reported minimal impact of postoperative voice rest on QoL. The participants attributed their success to facilitators such as notifying close contacts of their situation beforehand and adopting nonverbal forms of communication. No participant endorsed a negative attitude toward voice rest. Understanding the rationale for voice rest and the consequences of noncompliance were reported to be effective in encouraging compliance. CONCLUSION: Overall, the participants tolerated voice rest well owing to facilitators such as early preparation, lifestyle modifications, and understanding the rationale for voice rest. Social disconnect and work demands were barriers of voice rest. Moving forward, facilitators and barriers should be addressed in efforts to optimize the voice rest experience for future patient populations. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:361-366, 2024.

Development and Application of Automated Vocal Fold Tracking Software in a Rat Surgical Model.

OBJECTIVE: The rat is a widely used model for studying vocal fold (VF) function after recurrent laryngeal nerve injury, but common techniques for evaluating rat VF motion remain subjective and imprecise. To address this, we developed a software package, called RatVocalTracker1.0 (RVT1.0), to quantify VF motion and tested it on rats with iatrogenic unilateral vocal fold paralysis (VFP). METHODS: A deep neural network was trained to identify the positions of the VFs and arytenoid cartilages (ACs) in transoral laryngoscope videos of the rat glottis. Software was developed to estimate glottic midline, VF displacement, VF velocity, and AC angle. The software was applied to laryngoscope videos of adult rats before and after right recurrent and superior laryngeal nerve transection (N = 15; 6M, 9F). All software calculated metrics were compared before and after injury and validated against manually calculated metrics. RESULTS: RVT1.0 accurately tracked and quantified VF displacement, VF velocity, and AC angle. Significant differences were found before and after surgery for all RVT1.0 calculated metrics. There was strong agreement between programmatically and manually calculated measures. Automated analysis was also more efficient than nearly all manual methods. CONCLUSION: This approach provides fast, accurate assessment of VF motion in rats with minimal labor and allows for quantitative comparison of lateral differences in movement. Through this novel analysis method, we can differentiate healthy movement from unilateral VFP. RVT1.0 is open-source and will be a valuable tool for researchers using the rat model for laryngology research. LEVEL OF EVIDENCE: NA Laryngoscope, 134:340-346, 2024.

Long-term voice outcomes of medialization thyroplasty with adjustable implant for unilateral vocal fold paralysis.

OBJECTIVES: Medialization thyroplasty (MT) using various implants has been employed as a corrective procedure for unilateral vocal fold paralysis (UVFP). A newly developed APrevent® vocal implant system (VOIS) offers an innovative solution with a finely adjustable design. This study aimed to investigate the long-term functional voice outcomes and benefits of postoperative adjustments in patients receiving MT using the VOIS-implant. METHODS: This is a prospective case series study at single tertiary medical center. Fourteen adult patients diagnosed with UVFP received MT with the VOIS implant and were followed up for more than 1 year. Implant adjustment procedure by injecting 0.9% physiological saline solution was performed both during and after the surgery to optimize glottal closure and voice quality. Objective voice outcomes and acoustic parameters were assessed preoperatively and postoperatively at various timepoints. RESULTS: Thirteen patients (93%) received intraoperative balloon adjustment, ranging from 0.05to 0.12 ml. Four patients underwent adjustments postoperatively and exhibited a positive trend towards immediately improving acoustic voice quality. Our long-term results demonstrated a notable improvement after the surgery in voice quality, with significant decreases in VHI-30 and improvements in perceptual parameters of GRBAS scale, acoustic measures such as jitter and signal-to-noise ratio (p < 0.001) and cepstral peak prominence smoothed in sustained vowel and short sentences. The voice outcomes remained stable more than 1 year follow-up. CONCLUSIONS: Overall, MT with VOIS implantation provides a favorable long-term outcomes and stability in voice quality for patients with UVFP and also an effective tool for postoperative adjustment without major revision surgeries.

Surgical management of vocal cord nodules in children: Trends and outcomes.

OBJECTIVES: Vocal cord nodules (VCNs) are the most common cause of dysphonia in school-aged children, with potential negative impacts on quality of life including diminished self-esteem and academic performance. The standard of care for VCNs is conservative management which ranges from voice hygiene to speech therapy with a focus on voice otherwise known as voice therapy, with surgical excision reserved for refractory cases. Thus, few studies have analyzed outcomes of surgical management of VCNs. The purpose of this study is to assess the prevalence and efficacy of surgical excision of VCNs when compared to speech therapy. METHODS: Children with VCNs seen at a single tertiary care institution between 2015 and 2020 were identified by ICD-9 code 478.5 and ICD-10 code J38.2. Demographics, objective voice assessment, intervention, and follow-up assessment data were reviewed. Frequencies, medians, and interquartile ranges were calculated. Time to resolution and improvement were assessed by Cox proportional hazards model. Univariate logistic regression was performed. A P value of <0.05 was considered statistically significant. RESULTS: Three hundred sixty-eight patients diagnosed with VCNs were identified. 169 patients received intervention for VCNs, with 159 (43.2 %) receiving speech therapy alone and 5 (1.4 %) receiving surgery alone. On bivariate analysis, there was no significant difference in demographic features between treatment groups, however speech therapy patients did have a longer follow-up time. 154 patients underwent objective voice assessment at the time of VCN diagnosis. Among these patients, 95 (61.7 %) received speech therapy and 59 (40.3 %) received no intervention. Speech therapy patients had significantly higher pVHI scores, however there was no significant difference in CAPE-V Overall Severity scores or computerized voice assessment analysis. On Cox proportional hazards analysis, surgical intervention was associated with faster resolution and faster improvement of dysphonic symptoms. On binary logistic regression, surgery was associated with a significantly greater proportion of patients reporting resolution of dysphonic symptoms, however there was no significant difference in proportion of patients reporting improvement of dysphonia. CONCLUSION: For most patients with VCNs, conservative measures such as voice hygiene and speech therapy remain first line, however certain patients may benefit from the rapid improvement and resolution of symptoms that surgical intervention may provide.

Management of Bilateral Vocal Fold Paralysis: A Systematic Review.

OBJECTIVE: To review the current literature about epidemiology, etiologies and surgical management of bilateral vocal fold paralysis (BVFP). DATA SOURCES: PubMED, Scopus, and Cochrane Library. REVIEW METHODS: A systematic review of the literature on epidemiology, etiologies, and management of adult patients with BVFP was conducted through preferred reporting items for systematic reviews and meta-analyses statements by 2 investigators. RESULTS: Of the 360 identified papers, 245 were screened, and of these 55 were considered for review. The majority (76.6%) of BVFP cases are iatrogenic. BVFP requires immediate tracheotomy in 36.2% of cases. Laterofixation of the vocal fold was described in 9 studies and is a cost-effective alternative procedure to tracheotomy while awaiting potential recovery. Unilateral and bilateral posterior transverse cordotomy outcomes were reported in 9 and 7 studies, respectively. Both approaches are associated with a 95.1% decannulation rate, adequate airway volume, but voice quality worsening. Unilateral/bilateral partial arytenoidectomy data were described in 4 studies, which reported lower decannulation rate (83%) and better voice quality outcome than cordotomy. Revision rates and complications vary across studies, with complications mainly involving edema, granuloma, fibrosis, and scarring. Selective posterior cricoarytenoid reinnervation is being performed by more surgeons and should be a promising addition to the BVFP surgical armamentarium. CONCLUSION: Depending on techniques, the management of BVFP may be associated with several degrees of airway improvements while worsened or unchanged voice quality. The heterogeneity between studies, the lack of large-cohort controlled randomized studies and the confusion with posterior glottic stenosis limit the draw of clear conclusion about the superiority of some techniques over others.