Percutaneous Vocal Fold Lateralization in children - a case series of a Brazilian tertiary pediatric hospital (pediatric vocal fold lateralization cases in a Brazilian hospital).

OBJECTIVES: Percutaneous Vocal Fold Lateralization (PVFL) consists of external fixation with non-absorbable percutaneous suture of the vocal fold in a lateral position, under direct glottic visualization. The objective of this study is to determine the effectiveness of PVFL in a university pediatric hospital, as well as to describe the potential risks and complications of the surgery. METHODS: Retrospective cohort study, with data collected from electronic medical records. The study was approved by the Research Ethics Committee of the institution. Surgeries were performed with the modified Lichentenberg technique and data, and outcomes were analyzed. RESULTS: Six patients with Bilateral Vocal Fold Paralysis who underwent Percutaneous Vocal Fold Lateralization were evaluated. Three patients were male. The age at diagnosis ranged from 2 to 132 days (mean 10.5 days). The reason for investigating the upper airway was the presence of increased work of breathing and stridor. Five patients had a favorable clinical evolution, with spontaneous ventilation in room air and absence of stridor or ventilatory effort, without the need for tracheostomy. Surgical results in this series corroborate the findings of other similar cohorts, which showed Percutaneous Vocal Fold Lateralization as a safe and effective procedure in avoiding tracheostomy or allowing decannulation in children with Bilateral Vocal Fold Paralysis. CONCLUSIONS: PVFL seems to be a safe and effective procedure, but it has morbidity, due to immediate, and probably late, non-serious complications. Studies with a larger number of patients, with longer follow-up and using a controlled and randomized clinical design are needed to establish the role of PVFL in the treatment of BVFP in newborns and infants. LEVELS OF EVIDENCE: Level 4 (step 4).

Preliminary Correlation of the Immunoexpression of Cathepsin B and E-Cadherin Proteins in Vocal Fold Leukoplakia.

OBJECTIVES: Early identification of vocal fold leukoplakia (VFL), which has a risk of progressing to malignant transformation, remains a controversial topic. The identification of biological markers for diagnosing these lesions would lead to a more effective treatment. We aimed to analyze the immunoexpression of cathepsin B and E-cadherin in VFL and correlate it with clinical and epidemiological data and disease prognosis. METHODS: Thirty-two patients with VFL treated with microsurgery were retrospectively evaluated. The patients were distributed according to the histological results into Group A (low grade) and Group B (high grade). The expression of markers was quantitatively determined as per their staining intensity and tissue distribution using ImageLab. The index of expression (IE) of each marker was correlated with tobacco and alcohol consumption, signs of laryngopharyngeal reflux, and local recurrence of the lesion. RESULTS: The correlation between the IE of markers and variables within the two groups (A and B) demonstrated that patients in Group B with local recurrence had a higher IE of cathepsin B. When all patients (A + B) were included, the same analysis demonstrated that the IE of cathepsin B was higher among smokers and patients who did not show signs of reflux and that the IE of E-cadherin was higher only in patients with recurrence. CONCLUSION: Patients with moderate to severe dysplasia and carcinoma in situ who smoked as well as had a high IE of cathepsin B were more prone to local recurrence. Regardless of the type of histological lesion, patients with signs of laryngopharyngeal reflux had a lower IE of cathepsin B. The IE of E-cadherin was higher among patients with VFL who relapsed after initial treatment.

Development and validation of a 3D laryngeal model in surgical skills training.

OBJECTIVE: To present and validate a new simulation model for endoscopic phonomicrosurgery training as an improved teaching method. METHODS: A low-cost artificial model was assembled using 3D printing, silicone, and gelatin. The study was designed to test the model's ability to carry out training and teaching of endoscopic phonomicrosurgery. The synthetic model was built to simulate normal and pathological vocal folds such as polyps, intracordal cysts and keratoses, made of silicone and gelatin and embedded in a larynx framework made by 3D printing. Simulations of endoscopic surgical procedures were performed and documented through photographs and videos and the images were submitted to the evaluation of a group of 17 otorhinolaryngologists who used a Likert scale questionnaire. The responses were submitted to an agreement analysis using the sum of the scores obtained for the responses as an appropriate level of validation. Cronbach's alpha index was calculated to measure the degree of the questionnaire internal consistency. RESULT: The evaluations indicated maximum approval for the model adequacy for use in practical classes and for the teaching of the procedures, as well as in the overall satisfaction with the model in the use of surgical training. CONCLUSION: The present proposal for training laryngeal endoscopic surgery in a 3D synthetic model is a viable option according to the validation methodology used in the present study.

Inflammatory Myofibroblastic Tumor of the Larynx: Report of a Case.

PURPOSE: Inflammatory myofibroblastic tumor (IMT) is a rare tumor composed of mesenchymal myofibroblastic spindle cells enveloped by an inflammatory infiltrate. Historically, this tumor sparked debate regarding whether it was a true malignancy with metastatic potential or merely a locally destructive physiologic inflammatory response. Few reports of IMT exist in the recent literature, with the majority of cases occurring in the pediatric population and favoring the lungs. Here we present an exceedingly rare case of IMT involving the larynx of a 22-year-old female. RESULTS: A hemorrhagic and solid mass of the right true membranous vocal fold was excised and sent for histopathological assessment. Features of the surgical specimens were diagnostic for IMT. Intralesional steroid therapy was selected for additional treatment. Panendoscopy facilitated surveillance for any additional or recurrent lesions, of which there were none. At 11 months post-excision, follow-up MRI revealed symmetric vocal cords without evidence of any masses. CONCLUSIONS: Although rare, laryngeal IMT should be considered in any patient presenting with hoarseness due to a vocal fold mass. Based on the successful treatment of our patient, we suggest that our approach of surgical excision followed by intralesional corticosteroid injection may be an efficacious treatment approach for this rare tumor. However, more research is warranted to elucidate the most effective, safe, and cost-effective treatment approach.

Experimental model for controlled endoscopic subepithelial vocal fold injury in rats

Purpose: To present a detailed, reproducible, cost-efficient surgical model for controlled subepithelial endoscopic vocal fold injury in the rat model. Methods: Six male Sprague Dawley rats were enrolled in the experiment. The left vocal folds were used to carry out the injury model, and the right vocal fold served as control. After deep sedation, the rats were placed on a custom operating platform. The vocal fold injury by subepithelial stripping was carried out using custom-made microsurgical instruments under endoscopic guidance. Data were analyzed for procedural time and post-procedural pain. Microcomputed tomography (micro-CT) scan and histologic images were obtained to assess the length, area, and depth of injury to the vocal fold. Results: The mean procedural time was 112 s. The mean control vocal fold length was 0.96 ± 0.04 mm. The mean vocal fold injury length was 0.53 ± 0.04 mm. The mean vocal fold surface was 0.18 ± 0.01 mm2 with a mean lesion area of 0.05 ± 0.00 mm2. Mean vocal fold injury depth was 375.4 ± 42.8 µm. The lesion length to vocal fold length ratio was 0.55 ± 0.03, as well as lesion area to vocal fold surface area was 0.29 ± 0.02. Conclusions: Our described experimental vocal fold injury model in rats is found to be fast, safe, cost-efficient, and reproducible with a rapid learning curve.

Regenerative potential of basic fibroblast growth factor contained in biodegradable gelatin hydrogel microspheres applied following vocal fold injury: Early effect on tissue repair in a rabbit model / Potencial regenerativo do fator básico de crescimento de fibroblastos contido em microesferas biodegradáveis de hidrogel de gelatina aplicadas após lesão de prega vocal: efeito inicial no reparo tecidual em modelo de coelho

Abstract Introduction Postoperative dysphonia is mostly caused by vocal fold scarring, and careful management of vocal fold surgery has been reported to reduce the risk of scar formation. However, depending on the vocal fold injury, treatment of postoperative dysphonia can be challenging. Objective The goal of the current study was to develop a novel prophylactic regenerative approach for the treatment of injured vocal folds after surgery, using biodegradable gelatin hydrogel microspheres as a drug delivery system for basic fibroblast growth factor. Methods Videoendoscopic laryngeal surgery was performed to create vocal fold injury in 14 rabbits. Immediately following this procedure, biodegradable gelatin hydrogel microspheres with basic fibroblast growth factor were injected in the vocal fold. Two weeks after injection, larynges were excised for evaluation of vocal fold histology and mucosal movement. Results The presence of poor vibratory function was confirmed in the injured vocal folds. Histology and digital image analysis demonstrated that the injured vocal folds injected with gelatin hydrogel microspheres with basic fibroblast growth factor showed less scar formation, compared to the injured vocal folds injected with gelatin hydrogel microspheres only, or those without any injection. Conclusion A prophylactic injection of basic fibroblast growth factor -containing biodegradable gelatin hydrogel microspheres demonstrates a regenerative potential for injured vocal folds in a rabbit model.

Resumo Introdução A disfonia pós-operatória é causada principalmente por cicatrizes nas pregas vocais. Tem sido relatado que o manejo cuidadoso da cirurgia das pregas vocais reduz o risco de formação de cicatriz. No entanto, a depender da lesão da prega vocal, o tratamento da disfonia pós-operatória pode ser desafiador. Objetivo Desenvolver uma nova abordagem regenerativa profilática para o tratamento de pregas vocais lesionadas após a cirurgia, com microesferas biodegradáveis de hidrogel de gelatina como sistema de administração de medicamentos para o Fator Básico de Crescimento de Fibroblastos (bFGF). Método A cirurgia laríngea videoendoscópica foi feita para criar lesão nas pregas vocais em 14 coelhos. Imediatamente após esse procedimento, microesferas biodegradáveis de hidrogel de gelatina com bFGF foram injetadas na prega vocal. Duas semanas após a injeção, as laringes foram excisadas para avaliação da histologia das pregas vocais e do movimento da mucosa. Resultados A presença de função vibratória deficiente foi confirmada nas pregas vocais lesionadas. A histologia e a análise de imagem digital demonstraram que as pregas vocais lesionadas injetadas com microesferas de hidrogel de gelatina com bFGF apresentaram menor formação de cicatriz, em comparação com as pregas vocais lesionadas injetadas apenas com microesferas de hidrogel de gelatina ou aquelas sem injeção. Conclusão Uma injeção profilática de microesferas biodegradáveis de hidrogel de gelatina com bFGF demonstra um potencial regenerativo para pregas vocais lesionadas em um modelo de coelho.

Acute tissue damage induced by monopolar microelectrodes and radiofrequency in vocal cords after transoral cordectomy.

INTRODUCTION: In 2006 and 2009, we reported the levels of acute and chronic tissue damage after cordectomy associated with use of the microlectrodes using high frequency energy. In 2010, we shifted to radiofrequency rather than high frequency electrogenerators. OBJECTIVE: The aim of this study is to evaluate acute tissue damage in the larynx after cordectomy using microelectrodes coupled to a radiofrequencygenerator. METHODS: We studied 22 patients with a stage T1 glottic squamous cell carcinoma. The patients were randomly assigned to the two operating mode: cutting or coagulation (11 patients each mode). The strength of the study is that there are no previous studies on the effect of radiofrequency in human vocal cord. RESULTS: Tissue damage was milder when microelectrodes were coupled to a 4 MHz generator operating in the cutting mode. Thus, when using microelectrodes and radiofrequency, we recommend that the cutting mode be used for epithelial incision and the coagulation mode to treat the stroma and muscle and for final hemostasis. CONCLUSION: Microelectrodes and radiofrequency in transoral laryngeal surgery produced mild tissue damage and offer an excellent alternative to the use of high frequency energy.

Regenerative potential of basic fibroblast growth factor contained in biodegradable gelatin hydrogel microspheres applied following vocal fold injury: Early effect on tissue repair in a rabbit model.

INTRODUCTION: Postoperative dysphonia is mostly caused by vocal fold scarring, and careful management of vocal fold surgery has been reported to reduce the risk of scar formation. However, depending on the vocal fold injury, treatment of postoperative dysphonia can be challenging. OBJECTIVE: The goal of the current study was to develop a novel prophylactic regenerative approach for the treatment of injured vocal folds after surgery, using biodegradable gelatin hydrogel microspheres as a drug delivery system for basic fibroblast growth factor. METHODS: Videoendoscopic laryngeal surgery was performed to create vocal fold injury in 14 rabbits. Immediately following this procedure, biodegradable gelatin hydrogel microspheres with basic fibroblast growth factor were injected in the vocal fold. Two weeks after injection, larynges were excised for evaluation of vocal fold histology and mucosal movement. RESULTS: The presence of poor vibratory function was confirmed in the injured vocal folds. Histology and digital image analysis demonstrated that the injured vocal folds injected with gelatin hydrogel microspheres with basic fibroblast growth factor showed less scar formation, compared to the injured vocal folds injected with gelatin hydrogel microspheres only, or those without any injection. CONCLUSION: A prophylactic injection of basic fibroblast growth factor -containing biodegradable gelatin hydrogel microspheres demonstrates a regenerative potential for injured vocal folds in a rabbit model.

Comparison of the efficacy of vocal training and vocal microsurgery in patients with early vocal fold polyp / Comparação entre a eficácia do treinamento vocal e da fonocirurgia em pacientes com pólipo de prega vocal incipiente

Abstract Introduction: Vocal fold polyp is a benign proliferative disease in the superficial lamina propria of the vocal fold, and vocal microsurgery can improve the voice quality of patients with vocal fold polyp. In preliminary studies, we found that vocal training could improve the vocal quality of patients with early vocal fold polyp. Objective: This study aimed to compare the efficacies of vocal training and vocal microsurgery in patients with early vocal fold polyp. Methods: A total of 38 patients with early vocal fold polyp underwent 3 months of vocal training (VT group); another 31 patients with early vocal fold polyp underwent vocal microsurgery (VM group). All subjects were assessed using laryngostroboscopy, voice handicap index, and dysphonia severity index, and the efficacies of vocal training and vocal microsurgery were compared. Results: The cure rates of vocal training and vocal microsurgery were 31.6% (12/38) and 100% (31/31), respectively. The intragroup paired-sample t-test showed that the post treatment vocal handicap index, maximum phonation time, highest frequency (F0-high), lowest intensity (I-low), and dysphonia severity index in both the VT and VM groups were better than those before treatment, except for the jitter value. The intergroup independent-sample t-test revealed that the emotional values of vocal handicap index (t = − 2.22, p = 0.03), maximum phonation time (t = 2.54, p = 0.013), jitter (t = − 2.11, p = 0.03), and dysphonia severity index (t = 3.24, p = 0.002) in the VT group were better than those in the VM group. Conclusions: Both, vocal training and vocal microsurgery could improve the voice quality of patients with early vocal fold polyp, and these methods present different advantages.

Resumo Introdução: O pólipo de prega vocal é uma doença proliferativa benigna da camada superficial da lâmina própria da prega vocal e a microfonocirurgia pode melhorar a qualidade vocal desses pacientes. Em estudos preliminares, observamos que o treinamento vocal era capaz de melhorar a qualidade vocal de pacientes com pólipo incipiente de prega vocal. Objetivo: Este estudo teve como objetivo comparar a eficiência entre treinamento vocal e microfonocirurgia em pacientes com pólipo incipiente de prega vocal. Método: Um total de 38 pacientes com pólipo incipiente de prega vocal foram submetidos a três meses de treinamento vocal (grupo TV); outros 31 pacientes foram submetidos à microfonocirurgia (grupo MC). Todos os indivíduos foram avaliados por meio de laringoestroboscopia, índice de desvantagem vocal e índice de severidade da disfonia e a eficácia entre treinamento vocal e microfonocirurgia foi comparada. Resultados: As taxas de cura do treinamento vocal e da microfonocirurgia foram de 31,6% (12/38) e 100% (31/31), respectivamente. O teste t para amostras pareadas intragrupo mostrou que o índice de desvantagem vocal pós-tratamento, tempo máximo de fonação, frequência máxima, intensidade mínima e índice de severidade da disfonia nos grupos TV e MC foram melhores do que aqueles antes do tratamento, exceto pelo valor do jitter. O teste t para amostras independentes intergrupos revelou que o valor emocional do índice de desvantagem vocal (t = -2,22, p = 0,03), tempo máximo de fonação (t = 2,54, p = 0,013), jitter (t = -2,11, p = 0,03) e índice de severidade da disfonia (t = 3,24, p = 0,002) no grupo TV foram melhores do que os do grupo MC. Conclusões: Tanto o treinamento vocal quanto a microfonocirurgia podem melhorar a qualidade da voz de pacientes com pólipo incipiente de prega vocal e esses métodos apresentam diferentes vantagens.

A morphological classification for vocal fold leukoplakia / Classificação morfológica das leucoplasias de prega vocal

Abstract Introduction: There is still no general method for discriminating between benign and malignant leukoplakia and identifying vocal fold leukoplakia. Objective: To evaluate the reliability of a morphological classification and the correlation between morphological types and pathological grades of vocal fold leukoplakia. Methods: A total of 375 patients with vocal fold leukoplakia between 2009 and 2015 were retrospectively reviewed. Two observers divided the vocal fold leukoplakia into flat and smooth, elevated and smooth, and rough type on the basis of morphological appearance. The inter-observer reliability was evaluated and the results of classification from both observers were compared with final pathological grades. Clinical characteristics between low risk and high risk group were also analyzed. Results: The percentage inter-observer agreement of the morphological classification was 78.7% (κ = 0.615, p < 0.001). In the results from both observers, the morphological types were significantly correlated with the pathological grades (p1 < 0.001, p2 < 0.001, Kruskal-Wallis test; r1 = 0.646, p1 < 0.001, r2 = 0.539, p2 < 0.001, Spearman Correlation Analysis). Multivariate analysis showed patient's age (p = 0.018), the size of lesion (p < 0.001), and morphological type (p < 0.001) were significantly different between low risk group and high risk group. Combined receiver operating characteristic curve analysis of significant parameters revealed an area under the receiver operating characteristic curve of 0.863 (95% CI 0.823-0.903, p < 0.001). Conclusions: The proposed morphological classification of vocal fold leukoplakia was consistent between observers and morphological types correlated with pathological grades. Patient's age, the size of lesion, and morphological type might enable risk stratification and provide treatment guidelines for vocal fold leukoplakia.

Resumo Introdução: Ainda não há um método universal estabelecido para diferenciar entre a leucoplasia benigna e maligna ou identificar as leucoplasias das pregas vocais. Objetivo: Avaliar a confiabilidade de uma classificação morfológica e a correlação entre os tipos morfológicos e os graus histopatológicos das leucoplasias de pregas vocais. Método: Os registros de 375 pacientes com leucoplasia da prega vocal assistidos entre 2009 e 2015 foram revisados retrospectivamente. Dois observadores dividiram a leucoplasia da prega vocal entre tipo plano e liso, elevado e liso, e rugoso, com base na aparência morfológica. A confiabilidade interobservador foi avaliada e os resultados de classificação de ambos os observadores foram comparados com os graus histopatológicos finais. As características clínicas entre os grupos de baixo risco e alto risco também foram analisadas. Resultados: A porcentagem da concordância interobservador da classificação morfológica foi de 78,7% (κ = 0,615, p < 0,001). Nos resultados de ambos os observadores, os tipos morfológicos correlacionaram-se significativamente com os graus histopatológicos (p1 < 0,001, p2 < 0,001, teste de Kruskal-Wallis; r1 = 0,646, p1 < 0,001, r2 = 0,539, p2 < 0,001, análise de correlação de Spearman). A análise multivariada mostrou que a idade do paciente (p = 0,018), o tamanho da lesão (p < 0,001) e o tipo morfológico (p < 0,001) foram significativamente diferentes entre o grupo de baixo risco e o de alto risco. A análise da curva ROC (Receiver Operating Characteristic) combinada de parâmetros significativos revelou uma área sob a curva de 0,863 (IC 95%: 0,823 ± 0,903, p < 0,001). Conclusões: A classificação morfológica proposta para leucoplasia de prega vocal foi consistente entre observadores e os tipos morfológicos correlacionaram-se com os graus histopatológicos. A idade do paciente, o tamanho da lesão e o tipo morfológico podem permitir a estratificação de risco e fornecem diretrizes de tratamento para a leucoplasia da prega vocal.

The role of intraoperative narrow-band imaging in transoral laser microsurgery for early and moderately advanced glottic cancer / O papel da imagem de banda estreita intraoperatória na microcirurgia transoral a laser para câncer glótico inicial e moderadamente avançado

Abstract Introduction: Trans-oral laser microsurgery is an established technique for the treatment of early and moderately advanced laryngeal cancer. Objective: The authors intend to test the usefulness of narrow-band imaging in the intraoperative assessment of the larynx mucosa in terms of specifying surgical margins. Methods: Forty-four consecutive T1-T2 glottic cancers treated with trans-oral laser microsurgery Type I-VI cordectomy were presented. Suspected areas (90 samples/44 patients) were biopsied under the guidance of narrow-band imaging and white light and sent for frozen section. Results: Our study revealed that 75 of 90 (83.3%) white light and narrow-band imaging-guided samples were histopathologically positive: 30 (40%) were confirmed as carcinoma in situ or invasive carcinoma and 45 (60%) as moderate to severe dysplasia. In 6 patients mucosa was suspected only in narrow-band imaging, with no suspicion under white light. Thus, in these 6 patients 18/90 (20%) samples were taken. In 5/6 patients 16/18 (88.8%) samples were positive in frozen section: in 6/18 (33.3%) carcinoma (2 patients), 10/18 (66.6%) severe dysplasia was confirmed (3 patients). In 1 patient 2/18 (11.1%) samples were negative in frozen section. Presented analysis showed, that sensitivity, specificity and accuracy of white light was 79.5%, 20% and 71.1% respectively, while narrow-band imaging was 100%, 0.0% and 85.7%, respectively. Conclusion: The intraoperative use of narrow-band imaging proved to be valuable in the visualization of suspect areas of the mucosa. Narrow-band imaging confirms the suspicions undertaken in white light and importantly, it showed microlesions beyond the scope of white light.

Resumo Introdução: A microcirurgia transoral a laser é uma técnica bem estabelecida para o tratamento de câncer de laringe inicial e moderadamente avançado. Objetivo: Verificar a utilidade da imagem de banda estreita na avaliação intraoperatória da mucosa laríngea na especificação das margens cirúrgicas. Método: Foram avaliados 44 cânceres glóticos T1-T2 consecutivos, tratados com cordectomia Tipo I-VI, por microcirurgia transoral a laser. As áreas suspeitas (90 amostras/44 pacientes) foram submetidas a biopsia e avaliadas através de imagens de banda estreita e luz branca e enviadas para cortes por congelação. Resultados: Nosso estudo revelou que 75 (83,3%) das 90 amostras apresentaram histopatologia positiva na análise com luz branca e imagens de banda estreita: 30 (40%) foram confirmadas como carcinoma in situ ou carcinoma invasivo e 45 (60%) como displasia moderada a grave. Em seis pacientes, a mucosa apresentou-se suspeita apenas na imagem de banda estreita, sem suspeita sob luz branca. Assim, nesses seis pacientes 18/90 (20%) amostras foram colhidas. Em 5/6 pacientes, 16/18 (88,8%) amostras mostraram resultado positivo na análise de congelação: em 6/18 (33,3%) amostras foi confirmado carcinoma (dois pacientes) e em 10/18 (66,6%) foi confirmada displasia grave (três pacientes). Em um paciente, 2/18 (11,1%) as amostras mostraram resultado negativo na congelação. A análise apresentada mostrou que a sensibilidade, a especificidade e a acurácia da luz branca foram de 79,5%, 20% e 71,1%, respectivamente, enquanto a imagem de banda estreita apresentou como resultados 100%, 0,0% e 85,7%, respectivamente. Conclusão: O uso intraoperatório de imagem de banda estreita provou ser valioso na identificação de áreas suspeitas da mucosa, confirmou as suspeitas verificadas na análise com luz branca e, o que é mais importante, identificou microlesões além do alcance da luz branca.

Effects of diode laser setting for laryngeal surgery in a rabbit model.

PURPOSE: To study the damaging effect of different diode laser settings on vocal folds 7 days after injury in a rabbit model. METHODS: Twenty-one male New Zealand white rabbits were randomized into three groups with seven animals per group. A 980-nm diode laser was used to create a single spot injury in each vocal fold. Different modulation frequencies (10 Hz versus 1000 Hz) in pulsed mode, different powers (3 W versus 5 W), and distinct wave modes of radiation (pulsed versus continuous) were compared. RESULTS: The extent of the inflammatory infiltrate and ablation crater were greater when using 5-W optical power compared with 3 W. The extent and depth of the inflammatory infiltrate, and the width and depth of the ablation crater were greater with continuous wave mode compared with pulsed mode. The density of collagen fibers only increased when using the laser in continuous wave mode. CONCLUSION: The use of the 980-nm diode laser with an output power of 5 W produced an increased extent of thermal injury compared to an output power of 3 W and, more importantly, using continuous rather than pulsed wave mode significantly increased the extent and depth of thermal injury in rabbit vocal folds.

Adaptation and evaluation of a monopolar electrosurgical triangle-tip knife for transendoscopic ventriculocordectomy in healthy horses.

OBJECTIVE: To evaluate the efficacy and safety of a transendoscopic monopolar electrosurgical triangle-tip knife as instrumentation to perform unilateral ventriculocordectomy (VC) in healthy adult horses. STUDY DESIGN: In vivo experimental study. STUDY POPULATION: Nine horses donated for medical conditions unrelated to respiratory system. METHODS: The triangle-tip knife was applied in contact fashion. Left VC was performed under standing sedation. Endoscopic images of the upper airway were graded for inflammation by 2 masked surgeons preoperatively and immediately, 24 hours and, in 2 cases, 7 and 14 days postoperatively. Four larynxes were examined for histological evidence of inflammation and collagen deposition at 24 hours (n = 2) and at 14 days (n = 2) after surgery. RESULTS: Ventriculocordectomy was successfully performed in all horses. Endoscopic evidence of inflammation was scored as normal (preoperatively), mild (immediately postoperatively), mild (24 hours postoperatively), mild (7 days postoperatively), and normal (14 days postoperatively). According to histopathology, inflammation of the surgical site and ventricularis muscle was generally increased (variable is common and is present in most high-power fields) 24 hours and 14 days postoperatively. Fibrosis and collagen deposition also seemed increased at the surgical site 14 days postoperatively. CONCLUSION: Ventriculocordectomy was successfully performed with an electrosurgical triangle-tip knife and resulted in acceptable short-term outcomes. CLINICAL SIGNIFICANCE: The use of an electrosurgical triangle-tip knife alternative instrumentation may be offer an alternative option to perform VC in practices when diode laser is not available or is cost prohibitive. Longer term evaluation of the VC site is required to determine the effect on rima glottic cross-sectional area.

A morphological classification for vocal fold leukoplakia.

INTRODUCTION: There is still no general method for discriminating between benign and malignant leukoplakia and identifying vocal fold leukoplakia. OBJECTIVE: To evaluate the reliability of a morphological classification and the correlation between morphological types and pathological grades of vocal fold leukoplakia. METHODS: A total of 375 patients with vocal fold leukoplakia between 2009 and 2015 were retrospectively reviewed. Two observers divided the vocal fold leukoplakia into flat and smooth, elevated and smooth, and rough type on the basis of morphological appearance. The inter-observer reliability was evaluated and the results of classification from both observers were compared with final pathological grades. Clinical characteristics between low risk and high risk group were also analyzed. RESULTS: The percentage inter-observer agreement of the morphological classification was 78.7% (κ=0.615, p<0.001). In the results from both observers, the morphological types were significantly correlated with the pathological grades (p1<0.001, p2<0.001, Kruskal-Wallis test; r1=0.646, p1<0.001, r2=0.539, p2<0.001, Spearman Correlation Analysis). Multivariate analysis showed patient's age (p=0.018), the size of lesion (p<0.001), and morphological type (p<0.001) were significantly different between low risk group and high risk group. Combined receiver operating characteristic curve analysis of significant parameters revealed an area under the receiver operating characteristic curve of 0.863 (95% CI 0.823-0.903, p<0.001). CONCLUSIONS: The proposed morphological classification of vocal fold leukoplakia was consistent between observers and morphological types correlated with pathological grades. Patient's age, the size of lesion, and morphological type might enable risk stratification and provide treatment guidelines for vocal fold leukoplakia.

Prevalence of Minor Larynx Structural Alterations: Influence on the Concept of a Normal Vocal Fold.

OBJECTIVE: To determine the prevalence of minor structural alterations (MSA) in the vocal fold cover in a population submitted to extralaryngeal site surgery and to characterize them according to morphological and epidemiological parameters. STUDY DESIGN: This was a cross-sectional and observational study. SETTING: Tertiary referral medical center. SUBJECTS AND METHODS: A total of 147 patients underwent general anesthesia for extralaryngeal site surgery indicated for a procedure extraneous to the study and irrespective of the presence of vocal complaint. Next, detection and morphological characterization of MSAs in the vocal fold cover were performed by means of suspension microlaryngoscopy with laryngeal inspection and palpation without surgical intervention related to this procedure. The laryngeal findings were compared with variables from a clinical and demographic characteristics questionnaire given to these individuals. RESULTS: A 21.1% prevalence of MSAs was identified in the sample, which included a majority of individuals without vocal complaint (95.9%). Of these, 5.4% of individuals had laryngeal microdiaphragms, 16.3% sulcus vocalis, and 4.1% epidermoid cysts. No pouch sulcus or mucosal bridges were found. The identification of these alterations occurred mainly after 10 years of age, without effects of sex, vocal abuse, or upper airway conditions. The most common combination of MSAs was bilateral sulcus vocalis. CONCLUSIONS: The prevalence of MSAs in laryngeal coverage in this predominantly vocally asymptomatic population was 21.1%, with identification of sulcus vocalis, epidermoid cyst, and laryngeal microdiaphragm. Age was the only clinical or demographic characteristic associated with these alterations.

The role of intraoperative narrow-band imaging in transoral laser microsurgery for early and moderately advanced glottic cancer.

INTRODUCTION: Trans-oral laser microsurgery is an established technique for the treatment of early and moderately advanced laryngeal cancer. OBJECTIVE: The authors intend to test the usefulness of narrow-band imaging in the intraoperative assessment of the larynx mucosa in terms of specifying surgical margins. METHODS: Forty-four consecutive T1-T2 glottic cancers treated with trans-oral laser microsurgery Type I-VI cordectomy were presented. Suspected areas (90 samples/44 patients) were biopsied under the guidance of narrow-band imaging and white light and sent for frozen section. RESULTS: Our study revealed that 75 of 90 (83.3%) white light and narrow-band imaging-guided samples were histopathologically positive: 30 (40%) were confirmed as carcinoma in situ or invasive carcinoma and 45 (60%) as moderate to severe dysplasia. In 6 patients mucosa was suspected only in narrow-band imaging, with no suspicion under white light. Thus, in these 6 patients 18/90 (20%) samples were taken. In 5/6 patients 16/18 (88.8%) samples were positive in frozen section: in 6/18 (33.3%) carcinoma (2 patients), 10/18 (66.6%) severe dysplasia was confirmed (3 patients). In 1 patient 2/18 (11.1%) samples were negative in frozen section. Presented analysis showed, that sensitivity, specificity and accuracy of white light was 79.5%, 20% and 71.1% respectively, while narrow-band imaging was 100%, 0.0% and 85.7%, respectively. CONCLUSION: The intraoperative use of narrow-band imaging proved to be valuable in the visualization of suspect areas of the mucosa. Narrow-band imaging confirms the suspicions undertaken in white light and importantly, it showed microlesions beyond the scope of white light.

Comparison of the efficacy of vocal training and vocal microsurgery in patients with early vocal fold polyp.

INTRODUCTION: Vocal fold polyp is a benign proliferative disease in the superficial lamina propria of the vocal fold, and vocal microsurgery can improve the voice quality of patients with vocal fold polyp. In preliminary studies, we found that vocal training could improve the vocal quality of patients with early vocal fold polyp. OBJECTIVE: This study aimed to compare the efficacies of vocal training and vocal microsurgery in patients with early vocal fold polyp. METHODS: A total of 38 patients with early vocal fold polyp underwent 3 months of vocal training (VT group); another 31 patients with early vocal fold polyp underwent vocal microsurgery (VM group). All subjects were assessed using laryngostroboscopy, voice handicap index, and dysphonia severity index, and the efficacies of vocal training and vocal microsurgery were compared. RESULTS: The cure rates of vocal training and vocal microsurgery were 31.6% (12/38) and 100% (31/31), respectively. The intragroup paired-sample t-test showed that the post treatment vocal handicap index, maximum phonation time, highest frequency (F0-high), lowest intensity (I-low), and dysphonia severity index in both the VT and VM groups were better than those before treatment, except for the jitter value. The intergroup independent-sample t-test revealed that the emotional values of vocal handicap index (t=-2.22, p=0.03), maximum phonation time (t=2.54, p=0.013), jitter (t=-2.11, p=0.03), and dysphonia severity index (t=3.24, p=0.002) in the VT group were better than those in the VM group. CONCLUSIONS: Both, vocal training and vocal microsurgery could improve the voice quality of patients with early vocal fold polyp, and these methods present different advantages.

Quistes de cuerda vocal: experiencia en 44 pacientes del Centro de Voz del Departamento de Otorrinolaringología de la Pontificia Universidad Católica de Chile / Vocal Cord Cysts: experience in 44 patients from the Voice Center of the Department of Otorhinolaryngology Pontificia Universidad Católica de Chile

Introducción: Los quistes de cuerda vocal son una causa relativamente frecuente de disfonía. Su origen es aún controversial, y su diagnóstico y manejo continúan siendo un desafío clínico. Objetivo: Exponer y analizar las características clínicas de los quistes de cuerda vocal en nuestra serie de pacientes. Material y método: Estudio retrospectivo descriptivo de los pacientes con diagnóstico de quiste de cuerda vocal atendidos en nuestro centro entre junio de 2012 y diciembre de 2015. Resultados: Se atendieron 44 pacientes con diagnóstico de quiste de cuerda vocal, lo que representa el 4,32% de las consultas en nuestro Centro de Voz. La mayoría de los pacientes fueron adultos, y de ellos el 68,29% correspondió a mujeres. El 34,1% de los pacientes fueron sometidos a tratamíento quirúrgico con técnica de microfonocirugía. El 75% de los pacientes operados presentó mejoría en patrón de onda mucosa videolaringoestroboscópica. Todos los pacientes en los que se disponía de encuestas de valoración subjetiva de la voz pre y posoperatorias demostraron mejoría vocal significativa. Conclusión: Los quistes de cuerda vocal son lesiones que afectan a niños y adultos. La videolaringoestroboscopía es clave en el diagnóstico de estas lesiones, y el tratamiento quirúrgico con microfonocirugía es efectiva en cuanto a resultados vocales desde el punto de vista anatómico y funcional.

Introduction: Vocal cord cysts are a relatively frequent cause of dysphonia. Their origin is still controversial, and their diagnosis and management continue to be a clinical challenge. Aim: To describe and analyze the clinical characteristics of vocal cord cysts in our series of patients. Material and method: Descriptive retrospective study of patients with diagnosis of vocal cord cyst attended in our center between June 2012 and December 2015. Results: 44 patients had the diagnosis of vocal cord cyst, which represents 4.32% of the patients that attended our Voice Center during that period. Most of the patients were adults, and among them 68.29% corresponded to women. 34.1% of the patients were submitted to surgical treatment with microphonosurgery technique. 75% of the surgical patients presented an improvement in the pattern of the videolaryngostroboscopic mucosal wave. All the patients in which pre and postsurgical subjective voice assessment polls were available, showed a significant voice improvement. Conclusion: Vocal cord cysts are lesions that affect both children and adults. The videolaryngostroboscopy evaluation is key in the diagnosis of these lesions, and the surgical treatment with microphonosurgery is effective in terms of anatomical and functional vocal results.

Laryngeal surgical treatment in transgender women: A systematic review and meta-analysis.

OBJECTIVE: To identify the effects of laryngeal surgical treatment in the voice of transgender women, especially on the fundamental frequency (f0). STUDY DESIGN: We performed a systematic review in PubMed and Scopus in July 2016, covering the period between 2005 and 2016. METHODS: Inclusion criteria were studies in English or Portuguese about the laryngeal surgical treatment in transgender women, featuring experimental design, title, year of publication, country of origin, journal of publication, participants, intervention, results. For the meta-analysis, only studies that had control group were selected. Exclusion criteria were articles that mentioned the use of surgical techniques but did not use the procedure in research, animal studies, studies of revision, and postmortem studies. RESULTS: Four hundred and twenty-three articles were identified in the initial search; 94 were selected for analysis by two referees, independently. After applying all the selection criteria, five studies remained in the meta-analysis. The surgical procedures that were identified included laryngoplasty with or without thyrohyoid approximation, Wendler glottoplasty, cricothyroid approximation, laser glottoplasty reduction and the vocal fold shortening and retrodisplacement of anterior commissure. There was no significant difference between the experimental group and the control group in relation to f0. CONCLUSION: No randomized clinical trials and prospective cohort studies are available, and a small number of retrospective cohort and case-control studies of surgical techniques reveal an increase in the f0. The evidence produced is not conclusive regarding which surgical technique would be better for vocal treatment of transgender women. LEVEL OF EVIDENCE: NA Laryngoscope, 127:2596-2603, 2017.

Pólipo bilateral de cuerda vocal: presentación de un caso clínico / Bilateral vocal cord polyp: case report

Los pólipos de cuerda vocal son lesiones laríngeas benignas. Se asocian a micro-traumatismos por mal uso vocal que generan remodelación de la lámina propia y el epitelio. Es más frecuente en hombres entre los veinte y cuarenta años. En la gran mayoría de los casos se presenta de manera unilateral. Si bien estas lesiones están bien documentadas en la literatura, es raro encontrar presentaciones bilaterales, por lo que su enfrentamiento y manejo puede ser discutible. Se presenta el caso de una paciente de sexo femenino de 41 años, fumadora, que consulta por disfonía de larga data. Se diagnostican pólipos bilaterales de cuerda vocal, realizando una intervención quirúrgica en un tiempo, con un resultado favorable.

Vocal cord polyps are benign Iaryngeal lesions. They are associated to micro traumatisms because ofvocal misuse, generating a remodelation of the lamina propria and the epithelium. It is more common in men between twenty and forty years of age. In the vast majority of cases it unilaterally occurs. While these are well documented injuries in the literature, it is rare to find bilateral presentations, so their confrontation and management may be debatable. We present the case of a female patient, smoker, who consulted for chronic dysphonia. Bilateral vocal cord polyps were diagnosed, performing a bilateral resection with a positive outcome.