Laryngeal office-based procedures: A safe approach.

PURPOSE: Laryngeal surgeries using a flexible nasopharyngoscope equipped with an operative channel has gained popularity, with gradual increase in the variety of interventional office-based procedures, under local anesthesia. The purpose of this study is to analyze the tolerance of such procedures. MATERIALS AND METHODS: Retrospective cohort study. 337 cases were performed during 2 years. We collected the following data: type of pathology, type of procedure and modalities of anesthesia, adverse events. RESULTS: 19 % of the visits were for the purpose of Biopsy, 65 % for an injection, and Trublue Laser was utilized in 12 % of the procedures. Regarding the pathologies, 27 % were vocal fold paralysis, 18 % leukoplakia or another suspicious lesion, 15 % recurrent respiratory papillomatosis, 13 % neuromuscular disorder, 9 % vocal fold scarring, 7 % vocal cord atrophy and 6 % had an inflammatory presentation. Side effects were documented in 26 visits (7.7 %) and were minor in almost all the encounters: they included strong reflexive cough, deep throat pain, discomfort, gag reflex, anxiety, vagal discomfort, malaise, hypersalivation, nose pain, labile hypertension. More severe side effects were very rare and included septal wound and epistaxis, erythematous rash, dyspnea, and transient dysarthria. 13 procedures were either aborted, or canceled at initial steps, due to inability of the patient to tolerate the procedure and were rescheduled for general anesthesia. 97 % of the cases were released home after 1 h of surveillance. CONCLUSION: Office-based flexible interventional laryngoscopy under local anesthesia is a safe and well-tolerated procedure, with abundance of various interventions feasible on ambulatory, office-based setup.

Efficacy of platelet-rich plasma (PRP) in benign vocal fold lesions: a systematic review and meta-analysis.

OBJECTIVES: To evaluate the efficacy of platelet-rich plasma (PRP) in benign vocal fold lesions. METHODS: MEDLINE, Cochrane Central, Web of Science, and Scopus databases were searched in April 2023 for relevant clinical trials. Inclusion criteria were clinical trials evaluating the efficacy of PRP in benign vocal fold lesions. We conducted a comparative double-arm analysis using the pooled mean difference (MD) and 95% confidence interval (CI). Outcomes of interest included the vocal handicap index (VHI), the Jitter and Shimmer percentages, and the noise-to-harmonic ratio (NHR). RESULTS: Six studies matched the inclusion criteria. The pooled analysis shows that PRP was associated with significantly lower VHI scores compared with the control (MD = - 5.06, p < 0.01). Regarding the Jitter percentage, the PRP group was not superior to the control group at 2 and 4 weeks. However, the results revealed that PRP significantly reduced the Jitter percentage at 3 months (MD = - 0.61, p = 0.0008). The overall analysis favored the PRP arm significantly (p < 0.001). As for the Shimmer percentage, the combined effect estimate favored the PRP group (MD = - 1.22, p = 0.002). Subgroup analysis according to the time did not reveal any significant differences between studies at 2 weeks, 4 weeks, and 3 months. The analysis of the NHR outcome revealed a significant difference between both groups (MD = -1.09, p = 0.01). However, at 4 weeks, the treatment group had a significantly lower NHR % compared to the control group (MD = - 0.61, p = 0.02). There was no significant difference at 3 months (MD = - 2.14, p = 0.14). CONCLUSIONS: Platelet-rich plasma is effective in reducing VHI scores, Jitter and Shimmer percentages, and NHR values. This effect is more evident after follow-up, especially 3 months.

Pre- and post-operative voice therapy (PaPOV): Development of an intervention for patients with benign vocal fold lesions.

BACKGROUND: Pre- and post-operative voice therapy may improve voice and quality-of-life outcomes for patients undergoing phonosurgery to remove benign vocal fold lesions (BVFLs). However, what constitutes voice therapy in this population is poorly described, resulting in a poor evidence base, lack of clinical guidelines and unwarranted variation in management. In order to develop the evidence base, a robust, iterative process of intervention development work should precede feasibility testing and effectiveness studies. METHODS & PROCEDURES: Guidance for developing complex interventions, drawing on evidence, theory and modelling, was used to inform the development of a pre- and post-operative voice therapy intervention entitled 'PaPOV'. Data from four sources of evidence were synthesized using a published triangulation protocol. Data from a systematic review, national survey of current practice, expert interview study, and patient and public involvement conversations were used to populate a triangulation matrix, outlining components of a PaPOV. Data were coded to reflect areas of agreement, dissonance and silence with each component of the intervention. Based on this evidence, an assessment of convergence for each intervention component could be made. OUTCOMES & RESULTS: In total, 61 components of the PaPOV intervention were explored. Of these, 27 were categorized as having stability of consensus according to a priori criteria. A total of 34 failed to meet the criteria. This was more frequently due to silence (27) rather than dissonance (seven) in the data. By evidencing areas of agreement and stability of consensus across data sources, the validity of individual findings has been enhanced. Furthermore, the study has exposed specific areas of the intervention that lack consensus and require exploration through further intervention development studies. CONCLUSIONS & IMPLICATIONS: This systematic triangulation process has contributed to the development of a PaPOV intervention for patients with BVFLs. Exploration of specific components relating to the intervention will allow outstanding questions to be answered in preparation for feasibility testing. WHAT THIS PAPER ADDS: What is already known on the subject BVFLs cause dysphonia by preventing vocal fold closure, impacting on vibratory characteristics and increasing compensatory muscle tension. Management for these patients is variable with them being offered phonosurgery, voice therapy, pharmacological management or a combined approach. Pre- and post-operative voice therapy may improve both voice and quality-of-life outcomes. This patient group has unique complexities when considering voice therapy, including surgical preparation, wound healing and epithelial mobilization. What this paper adds to existing knowledge This study uses a robust triangulation process to synthesize current evidence and patient experiences in order to inform the development of a PaPOV. It outlines some of the key components and considerations when delivering pre- and post-operative voice therapy to adults with BVFLs. Furthermore, it serves as a methodological example for intervention development in complex interventions, highlighting key guidance and recommended processes for developing and evaluating complex interventions. What are the potential or actual clinical implications of this work? The 61 components discussed as potential 'ingredients' for a PaPOV enable clinicians to reflect on key considerations when planning and delivering voice therapy to adults with BVFLs. This study highlights the pitfalls both clinically and in research of failing to describe interventions adequately and the benefits of using accurate, specific and agreed terminology in clinical practice, such as that outlined in the Rehabilitation Treatment Specification System (TRSS).

Evaluation of Postural Changes Using Dynamic Posturography after Speech Rehabilitation in Patients with Voice Disorders: A Longitudinal Study.

BACKGROUND: The association between voice and body posture is consensual across the scientific literature and seems to be established both ways. Any changes in normal posture can influence the mechanisms of vocal production; on the other hand, vocal rehabilitation can influence posture. OBJECTIVES: This study aimed to evaluate the postural pattern in subjects with organic voice disorders before and after speech rehabilitation, using computerised dynamic posturography (CDP). METHODS: In this prospective cohort study, 21 patients affected by dysphonia caused by benign vocal fold lesions, never treated with speech therapy/vocal training, were submitted to a posturographic analysis using CDP before and after vocal rehabilitation/therapy. Each patient underwent an accurate voice and ear, nose, and throat (ENT) anamnesis, a general ENT examination, a rigid and flexible laryngoscopy, a videolaryngostroboscopy, an acoustic voice analysis including aerodynamic evaluation, and a perceptual evaluation of voice using the Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) scale and the Voice Handicap Index (VHI) questionnaire, before and after vocal therapy. Fifteen healthy age- and sex-matched volunteers were also submitted to a posturographic analysis on the day of recruitment and 4 weeks later. RESULTS: All patients showed an improvement in voice quality after vocal training. The VHI decreased in all subjects, and the GRBAS scale showed a decrease in all parameters in each vowel (/a/, /i/, /e/) and in spontaneous speech (p < 0.001 for all). Posturographic results showed an improvement in equilibrium score, in conditions 2-6 and composite score. Strategic analysis results showed an improvement in conditions 1-6. CONCLUSIONS: The posturographic analysis showed a significant difference in the visual, vestibular, and proprioceptive component of posture after voice therapy. These results showed that dysphonic patients changed their postural patterns after an effective voice treatment, with an improvement in postural performance. It seems like modifications of breathing pattern and voice production techniques led to objective and measurable postural changes.

The association of sulcus vocalis and benign vocal cord lesions: intraoperative findings.

OBJECTIVE: To investigate the presence of sulcus vocalis in patients who underwent phonomicrosurgery due to benign vocal cord lesions. METHODS: Between January 2013 and June 2018, the records of 133 patients who underwent operations for benign vocal fold pathology were retrospectively reviewed. Intraoperative findings of the patients were noted. Patients were divided into two groups: patients with only benign vocal fold lesions (BVFL) and patients with benign vocal fold lesions and accompanying sulcus vocalis (SV + BVFL). RESULTS: In total, 67 patients (50.4%; 38 females, 29 males) had BVFL and 66 (49.6%; 37 females, 29 males) had SV + BVFL. The patients in the SV + BVFL group were significantly younger than those in the BVFL group (p = 0.039). The sulcus was unilateral in 60.6% of the patients. The presence of sulcus vocalis was 49% and 47.6% in patients with a diagnosis of polyps (n = 51) and cysts (n = 42), respectively. A total of 12 of 13 patients with multiple benign vocal fold lesions had accompanying sulcus vocalis. CONCLUSION: Approximately half of the patients who underwent operations for benign vocal fold lesions had accompanying sulcus vocalis. More than half of the sulcus associated with benign lesions was unilateral.

Laryngopharyngeal Reflux and Benign Vocal Fold Lesions: A Systematic Review and Meta-analysis.

OBJECTIVE: There is a link between laryngopharyngeal reflux (LPR) and the formation of benign vocal fold lesions (BVFLs). However, previous studies have mainly focused on LPR suggested by symptoms and signs, rather than objectively diagnosed LPR via pharyngeal pH monitoring. We, therefore, conducted a Meta-analysis to evaluate the association between pharyngeal pH monitoring diagnosed LPR and the odds of BVFLs. DATA SOURCES: Relevant observational studies were identified by searching PubMed, Embase, Cochrane Library, and Web of Science. REVIEW METHODS: We evaluated between-study heterogeneity using the Cochrane Q test and estimated the I2 statistic. Random-effects models were used when significant heterogeneity was observed; otherwise, fixed-effects models were used. RESULTS: Thirteen datasets from 9 studies were included. Among them, 493 were diagnosed with LPR and 344 had BVFLs. LPR was related to a higher odds of BVFLs (odds ratio: 3.26, 95% confidence interval: 1.84-5.76, P < .001) with moderate heterogeneity (P for Cochrane Q test = .006, I2 = 57%). Subgroup analyses showed that the association was similar in studies with only pharyngeal pH monitoring (Restech), with double-probe or 3-site pH monitoring, and with 24-hour multichannel intraluminal impedance-pH monitoring (P for subgroup difference = .15). In addition, subgroup analysis showed consistent results in studies from Asia and Europe (P for subgroup analysis = .12), and the association seemed to be consistent for vocal Reinke's edema, nodules, and polyps (P for subgroup difference = .09). CONCLUSION: Pharyngeal pH monitoring diagnosed LPR is associated with the formation of BVFLs.

Pre- and post-operative voice therapy for benign vocal fold lesions: protocol for a non-randomised, multicentre feasibility trial with embedded process evaluation.

BACKGROUND: Management of benign vocal fold lesions (BVFLs) is variable with individuals receiving surgery, voice therapy, or a combination of these approaches. Some evidence suggests that the best outcomes may be achieved when patients are offered pre- and post-operative voice therapy in addition to phonosurgery, but what constitutes pre- and post-operative voice therapy is poorly described. The pre- and post-operative voice therapy (PAPOV) intervention has been developed and described according to the TIDieR checklist and Rehabilitation Treatment Specification System (RTSS) for voice. The PAPOV intervention is delivered by specialist speech and language therapists trained in the intervention and comprises 7 essential and 4 additional components, delivered in voice therapy sessions with patients who are having surgery on their vocal folds for removal of BVFLs. STUDY DESIGN: Non-randomised, multicentre feasibility trial with embedded process evaluation. METHOD: Forty patients from two sites who are due to undergo phonosurgery will be recruited to receive the PAPOV intervention. Measures of feasibility, including recruitment, retention, and adherence, will be assessed. The feasibility of gathering clinical and cost effectiveness data will be measured pre-treatment, then at 3 and 6 months post-operatively. An embedded process evaluation will be undertaken to explain feasibility findings. DISCUSSION: This study will assess the feasibility of delivering a described voice therapy intervention protocol to patients who are undergoing surgery for removal of BVFLs. Findings will be used to inform the development and implementation of a subsequent effectiveness trial, should this be feasible. TRIAL REGISTRATION: This trial has been prospectively registered on ISRCTN (date 4th January 2023), registration number 17438192, and can be viewed here: https://www.isrctn.com/ISRCTN17438192 .

Relationships Between Vocal Fold Adduction Patterns, Vocal Acoustic Quality, and Vocal Effort in Individuals With and Without Hyperfunctional Voice Disorders.

OBJECTIVES/HYPOTHESIS: Increased vocal effort and aberrant vocal quality are often attributed to vocal fold hyperadduction in hyperfunctional voice disorders. However, there are currently no established methods to quantify vocal fold adduction beyond subjective descriptors in this clinical population. Furthermore, relationships between vocal fold adduction patterns, vocal effort severity, and vocal quality are not well characterized. Therefore, the objectives of this study were to (1) quantify vocal fold adduction, applying a previously validated method developed for patients with vocal fold paralysis, and (2) correlate these measures with acoustic vocal quality and self-perceived measures of vocal effort severity. METHODS: A deep learning program, Automated Glottic Action Tracking using artificial Intelligence, was used to track glottic angle configurations and vocal fold adduction velocities on laryngoscopic videos across 60 laryngoscopies (20 primary muscle tension dysphonia [pMTD], 20 phonotraumatic lesions, and 20 healthy controls). Voice samples were also acquired, and cepstral peak prominence (CPP) and H1-H2 acoustic measures were used to quantify vocal quality. Participants were also asked to rate their vocal effort on a 100 mm visual analog scale. RESULTS: There were no significant group differences in glottic angle configurations or vocal fold adduction velocities, although there were trends toward increased peak vocal fold adduction velocities in patients with hyperfunctional voice disorders compared to controls. Vocal effort was significantly higher in the two hyperfunctional groups compared to controls. CPP was significantly lower in the pMTD group, but there were no group differences in acoustic parameters between any of the other groups or for H1-H2 values. CONCLUSION: Despite significantly more vocal effort reported in patients with hyperfunctional voice disorders, there were no significant group differences in vocal fold adduction patterns. These findings suggest other physiologic mechanisms may also be responsible for the symptoms and genesis of pMTD and benign vocal fold lesions.

Pre and Post-operative Voice Therapy Intervention for Benign Vocal Fold Lesions: A Systematic Review.

Benign vocal fold lesions cause dysphonia by preventing vocal fold closure, causing irregular vibration and increasing compensatory muscle tension. Voice therapy delivered in addition to phonosurgery may improve voice and quality of life outcomes but the evidence base is lacking and what constitutes voice therapy for this population is not defined. The purpose of this systematic review is to critically evaluate the evidence for pre and post-operative voice therapy to inform the development of an evidence based intervention. STUDY DESIGN: Systematic Review. METHODS: Electronic databases were searched using key terms including dysphonia, phonosurgery, voice therapy and outcomes. Eligible articles were extracted and reviewed by the authors for risk of bias and for information regarding the content, timing and intensity of any pre and post-operative voice therapy intervention. RESULTS: Of the 432 articles identified, 35 met the inclusion criteria and were included in the review. 5 were RCTs, 2 were individual cohort studies, 1 was a case control study and 26 were case series. There was considerable heterogeneity in participant characteristics. Information was frequently lacking regarding the content timing and intensity of the reported voice therapy intervention, and where present, interventions were highly variable. CONCLUSION: Reporting in relevant literature is limited in all aspects of content, timing and intensity of intervention. Further intervention development work is required to develop a robust voice therapy treatment intervention for this population, before effectiveness work can commence.

Pre- and Postoperative Voice Therapy for Benign Vocal Fold Lesions: An International Electronic Delphi Consensus Study.

INTRODUCTION: Voice therapy management of benign vocal fold lesions (BVFLs) is variable and there are currently no clinical guidelines. Poor descriptions of voice therapy interventions lead to unwarranted variation in treatment. Triangulation of the current evidence identifies a number of potential best practice elements, but also a number of outstanding questions to be explored. The aim of this study was to refine and gain global consensus on "best practice" for a pre- and postoperative voice therapy intervention for adults with BVFLs. METHODS: An international sample of expert voice therapists (n = 42) were recruited to take part in this three-round electronic modified Delphi study. Participants were presented with statements concerning a pre- and postoperative voice therapy intervention. Statements were developed from previous research and based on the TIDieR checklist (eg, why, when, what, how?) Participants rated the extent to which they agreed or disagreed with a statement and gave comments to support their response. Consensus was defined as >75% of participants agreeing or strongly agreeing with a given statement. If consensus was not reached, participant comments were used to generate new statements and were rated in the next round. Stability of consensus between rounds was assessed. RESULTS: The 42 international experts achieved consensus on 33 statements relating to components of a best practice pre- and postoperative voice therapy intervention for patients with BVFLs. Consensus on statements ranged from 81% to 100%. These statements were explicitly mapped to the TIDieR checklist to ensure that all aspects of the intervention were considered and the questions of "why, what, how, when and individual tailoring" were addressed. CONCLUSIONS: This study has significantly enhanced our understanding of what should be in a best practice pre- and postoperative voice therapy intervention. It is important to now test these findings for acceptability and feasibility, prior to considering effectiveness research.

Age-dependent treatment effect of vocal fold steroid injection for benign vocal fold lesions.

Objective: Benign vocal fold lesions (BVFLs) cause voice disorders and impair social life. Recently, office-based vocal fold steroid injection (VFSI) has gained attention as a minimally invasive treatment for BVFLs. This study aimed to analyze the age-dependent treatment effect of VFSI and to clarify the indications for treatment. Methods: In this retrospective cohort study, a total of 83 patients with BVFLs were treated with a similar regimen of VFSI. Three or four months after the injection, age-dependent phonological functions were evaluated. The differences between pre- and post-treatment findings were analyzed using the Wilcoxon matched-pair signed-rank test, and the correlation between patient age and improvement rates were determined by Pearson's correlation coefficient. Results: Improvement in voice handicap index (VHI), which was the primary endpoint, was observed. Subjective and objective voice quality measurements also showed significant improvements. Subgroup analyses revealed that there was no age-related difference in the improvement of voice quality and that there was no improvement in aerodynamic effect in patients over 45 years of age. Conclusion: This study clarified the age-dependent treatment effect of VFSI and provided the important suggestion of establishing indication criteria for BVFLs. The study results provided clarity on the indication criteria of VFSI and served as an important indicator for tailoring treatment to patients' needs. Level of Evidence: 4.

The Comparison of Narrow Band Imaging, White Light Laryngoscopy and Videolaryngostroboscopy in the Evaluation of Benign Vocal Fold Lesions.

BACKGROUND: The aim of the study was comparing the diagnostic role of the white light (WL) endoscopy, video laryngostroboscopy (VLS), and narrow-band imaging (NBI) in the evaluation of the benign vocal fold lesions. MATERIAL AND METHODS: From March 2018 to June 2019, a total of 118 cases were enrolled in this study. Ninety-eight patients were suspected with vocal fold nodules, cysts, polyps, and sulcus vocalis and 20 patients without a history of dysphonia. Each patient was examined by WL, VLS, and NBI endoscopy. Recorded images and videos were analyzed and scored by three otorhinolaryngologists who had at least 3 years of experience in phoniatrics field. The evaluation results were compared between the methods and the physicians. RESULTS: A total of 118 cases were grouped by their confirmed diagnosis, vocal fold nodules (n = 28), vocal fold cyst (n = 24), vocal fold polyp (n = 9), and sulcus vocalis (n = 37). When the correct diagnosis rates of the physicians were compared, the statistical significance was found between the physicians in the WL and VLS method (P= 0.014, P= 0.027). No statistically significant difference was found among physicians in NBI method (P = 0.368). The difference between the diagnostic methods was found to be statistically significant in reaching the accurate diagnosis for benign vocal fold lesions (P< 0.001). While the difference between NBI-WL and VLS-WL was statistically significant (P< 0.001 and P< 0.001). The difference between NBI-VLS was not statistically significant while evaluating the vocal fold nodules, cysts, and sulcus vocalis separately (P= 0.102, P = 0.026, P = 0.157). Otherwise, it was statistically significant (P= 0.002) while evaluating total benign lesions in the study. The difference between NBI-VLS combination and VLS, NBI-VLS combination and VLS-WL combination were statistically significant (P< 0.001 and P= 0.001). CONCLUSION: This study showed that NBI assessments have similar accuracy and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to VLS and have a higher value than WL endoscopy in reaching the diagnosis for benign vocal fold lesions. Therefore, NBI can be accepted as a promising approach to identify benign laryngeal lesions due to its optical properties.

Risk factors for postoperative vocal fold fibrosis following microlaryngeal surgery.

Objective: To analyze the risk factors for postoperative vocal fold fibrosis (PVF) in patients undergoing microlaryngeal surgery (MLS) for benign vocal fold lesions. Study Design: Retrospective study. Methods: We retrospectively included patients who had undergone MLS for vocal polyps, nodules, mucus retention cysts, fibrous mass, or Reinke's edema. Data on the patients' clinicodemographic characteristics and intraoperative findings were obtained by reviewing their clinical records. PVF was defined by the presence of an adynamic segment of membranous vocal folds or a marked reduction in mucosal wave amplitude on post-MLS (6 weeks) videolaryngostroboscopy. The risk factors for PVF were analyzed through univariate and multivariate logistic regressions. Results: This study included 89 patients, of whom 16 (18%) were given a diagnosis of PVF. A significantly increased incidence of PVF was noted in patients with fibrous mass (p < .01). The univariate analysis indicated that lesion attachment to the vocal ligament, prolonged surgical duration (>60 min), and symptom duration (>12 months) were significantly correlated with PVF (p < .05). The multivariate analysis confirmed that diagnosis of fibrous masses, lesion attachment to the vocal ligament and symptom duration are significant risk factors for PVF. Conclusion: PVF is more common in patients with fibrous masses. Lesions attachment to the vocal ligament and prolonged symptom duration appear to be other significant risk factors for PVF. Level of Evidence: 4.

Pre- and Postoperative Voice Therapy for Benign Vocal Fold Lesions: Factors Influencing a Complex Intervention.

OBJECTIVES: (1) To describe factors influencing the content, timing, and intensity of pre- and postoperative voice therapy for patients undergoing phonosurgery for benign vocal fold lesions. (2) To understand experts' rationale for decisions made. (3) To critically analyze factors influencing intervention in relation to the wider literature in order to contribute to the development of a complex intervention. DESIGN: Qualitative interview study. SETTING: Multidisciplinary voice clinics in England. PARTICIPANTS: Ten expert voice therapists with a mean of 22 years experience. MAIN OUTCOME MEASURES: Participants were asked to describe factors influencing their current practice and views on optimum treatment for patients undergoing phonosurgery for benign vocal fold lesions. Data were analyzed using the Framework Method of thematic analysis. RESULTS: Factors influencing intervention related to four key themes. Pathophysiological, Patient, Therapist, and Service factors influenced the content, timing, and duration of the voice therapy provided. Consensus on core elements included delivering indirect and direct therapy preoperatively to manage underlying causative factors and address patient expectations. Postoperative intervention focused on indirect therapy to facilitate wound healing and direct therapy to improve vibratory characteristics of the vocal fold. Elements of therapy were highly individualized within participants according to the four themes above, but similarity between participants on broad parameters of intervention was high. CONCLUSIONS: Expert voice therapists use direct and indirect methods pre- and postoperatively to treat patients with benign vocal fold lesions. Optimizing wound healing and mobilization of the epithelium postoperatively are concerns for expert voice therapists which distinguish postoperative patients from other dysphonic patients. This study provides an insight into the factors influencing clinician's intervention provision which can contribute to the development of an optimal pre- and postoperative voice therapy intervention. Further research to refine and test the effectiveness of an intervention is now required.

Systematic Review of Recurrence Rates of Benign Vocal Fold Lesions Following Surgery.

OBJECTIVES: Benign vocal fold lesions which include vocal fold nodules, polyps, cysts and other lesions often recur after surgery and require additional treatments. This systematic review of the current literature evaluated the effects of adjunctive therapies in addition to surgical resection on the recurrence rates of benign vocal fold lesions in adults. STUDY DESIGN: Systematic review. METHODS: A search using relevant keywords in electronic databases was conducted. Extracted data include author, year of publication, patient demographics, diagnostic approach, lesion type, surgical procedure, type of adjunctive therapy and the rates of recurrence. Descriptive statistics were performed on the collected data when appropriate. RESULTS: Eleven articles were identified with a total of 1085 patients. The total 1101 lesions studied included 591 (53.7%) polyps, 125 (11.4%) nodules, 146 (13.3%) cysts, 184 (16.7%) pseudocysts, 19 (1.7%) midfold masses, 18 (1.6%) sulcus vocalis and 18 (1.6%) varices. Besides surgery, adjunctive therapies included voice therapy, steroid injection and reflux medication. There were 141 reported lesion recurrences, with an average recurrence rate of 13.0%. The recurrence rate in studies with adjunctive therapies was 7.14%, and in studies with no adjunctive therapies it was 24.44%. CONCLUSIONS: Available evidence suggests that adjunctive therapies following surgery are associated with decreased lesion recurrence rates. However, due to differences in sample size, inconsistent reporting of lesion characteristics, heterogeneity of adjunctive therapies, variability in follow-up time across studies, and other factors, it is not possible to determine exactly which adjunctive therapies are of significant benefit and which lesion types may benefit the most.

Pediatric Voice Handicap Index (pVHI): A Tool for Evaluating the Reliability and Validity of Voice Therapy in Children With Benign Vocal Fold Nodules.

OBJECTIVES: benign vocal fold lesions (BVFLs) represent the most common etiology of voice disorders in paediatric population, cause of dysphonia by preventing full vocal fold closure and modifying vibratory characteristics. Of those pathologies, vocal fold nodules represent almost 63% of the cases in children between 0-14 years. Management may include a combination of phonosurgery, voice therapy and pharmacological treatment, but almost 95% of otolaryngologists recommend voice therapy as primary treatment. The Pediatric Voice Handicap Index (pVHI) is nowadays widely used and accepted in the evaluation and monitoring of paediatric patients with dysphonia. The aim of our study was to demonstrate the reliability and validity of PVHI in the evaluation of the effects of voice therapy as treatment of vocal fold nodules in the paediatric population. PATIENTS AND METHOD: in this retrospective chart review twenty-seven (27) dysphonic patients with bilateral vocal fold nodules were treated with behavioral voice therapy approaches, and the PVHI surveys was administered to each patient parent's before and after therapy. The age of the patients ranged from 4 to 14 years (mean age 8.7 y-o); 17 (63%) were male and 10 (37%) females. RESULTS: according to our results, behavioral voice therapy effectively improved pVHI scores from pre- to post-treatment in paediatric patients with bilateral vocal fold nodules.

Correlation of Clinical and Pathological Diagnosis and Inflammatory Markers for Patients Undergoing Laryngeal Microsurgery.

BACKGROUND: The purpose of this study was to investigate the rate of concordance between indirect- and direct laryngoscopy and final pathology in patients undergoing laryngeal microsurgery. STUDY DESIGN: Retrospective case study. METHODS: This study was conducted in the Otolaryngology clinic of a tertiary center between January 2017 and June 2020. Archives records of 432 patients, who underwent laryngeal microsurgery because of benign and premalignant lesions or malignancy, were examined. The patients were divided into three subgroups according to pathology results: benign lesions, premalignant lesions, and malignancies. RESULTS: There were 400 laryngeal lesions from 385 patients, that met the inclusion and exclusion criteria, 307 (79.7%) were male and 78 were (20.3%) female. The average age of patients was 52.88 ± 13.21 years. The most common diagnosis was polyp (34.25%) followed by squamous cell carcinoma (27.75%) and Reinke's edema (8.25%) according to final pathology. For the benign laryngeal lesions, a high correlation level was observed regarding the compatibility of the indirect- and direct laryngoscopy diagnosis, and final pathology (P < 0.001). The laryngeal premalignant lesions and malignancies were significantly more common in older age and male gender (P <0.001). Similarly, smoking usage was more frequent in patients with premalignant lesions and malignancy (P <0.001). The neutrophil count, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, neutrophil to platelet ratio as well as CRP value were significantly higher in malignancy group (P <0.05). On the other hand, lymphocyte ratio was smaller in the malignancy group compared with the benign and premalignant lesions, and this difference was significant (P = 0.016). CONCLUSION: Our study demonstrated a high rate of agreement between the clinical diagnosis and pathology results in patients with benign laryngeal lesions, in contrast to premalignant lesions and malignancies. Also, the neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, neutrophil to platelet ratio as well as CRP were shown to be increased in patients with laryngeal malignancies.

Combining Voice Rest and Steroids to Improve Diagnostic Clarity in Phonotraumatic Vocal Fold Injury.

OBJECTIVES: (1) To describe a combination voice rest and steroid regimen to clarify ambiguous diagnoses in singers who present with phonotraumatic lesions and (2) to determine which videostroboscopic parameters show the most consistent response to this regimen. STUDY DESIGN: Chart review. METHODS: Singers with phonotraumatic vocal fold lesions seen at a tertiary care voice center over a 10-year period were identified. Those who had uncertain diagnoses on initial presentation, completed a combination regimen including voice rest and steroids, and had follow-up examinations were included in the analysis. The effect of this combination regimen was assessed by ratings of pre- and postregimen videostroboscopy examinations and by auditory perceptual ratings. Whether the combination regimen clarified the diagnosis was noted. RESULTS: Twenty-nine singers were prescribed the combination regimen with the intent to clarify the diagnosis. In 79% (23/29) of these singers, the regimen helped clarify diagnosis, for example, ruling in or ruling out specific lesions, confirming areas of scar, or distinguishing acute from chronic phonotraumatic injury. Stroboscopic exams were improved in 86% (25/29). The most common stroboscopic finding was a reduction in the lesion size (66%). Auditory perceptual ratings improved in 48% (14/29) of patients. CONCLUSIONS: A "cool down" combination of voice rest and steroids can improve diagnostic clarity in a subset of singers with phonotraumatic lesions. This combination regimen can be considered, with both the side effect profile of steroids and possible financial ramifications of strict voice rest in mind, when the initial diagnosis is unclear.

Ectopic Laryngeal Ossification after Bone Morphogenetic Protein-2.

We report two cases of ectopic bone formation in the head and neck following treatment with recombinant human bone morphogenetic protein-2 (rhBMP-2). Surgical pathologic data, laryngoscopy imaging, CT imaging, and patient medical history were obtained. First, we report osseous metaplasia in the vocal fold in a 67-year-old male following mandibular dental implants with rhBMP-2; second, a case of severe bony overgrowth of the larynx and fusion to the anterior cervical spine (ACS) in a 73-year-old male following multiple anterior cervical discectomies and fusions with rhBMP-2. Ectopic bone formation following rhBMP-2 has been previously reported. Adverse events like local swelling and edema leading to dysphagia and even airway obstruction after cervical spine application of rhBMP-2 have also been widely reported. Due to the uncommon nature of abnormal bony growth in soft tissue areas of the head and neck and the previously documented adverse effects of rhBMP-2 use, especially in the cervical spine, we consider the two unusual case presentations of ectopic bony formation highly likely to be linked with rhBMP-2. We urge awareness of the adverse effects caused by rhBMP-2, and urge caution in dosing.

Comparison of therapeutic effects of steroid injection by benign vocal fold lesion type.

BACKGROUND: Benign vocal fold lesions (BVFLs) can cause voice changes, including reduced loudness and pitch range. In recent times, with progression in endoscopic technology, office-based vocal fold steroid injection (VFSI) has been used as an alternative therapy for BVFLs. AIMS/OBJECTIVES: In this study, we analyzed the efficacy and safety of VFSI to investigate the mechanism underlying its therapeutic effects and determine the conditions in which VFSI will be most effective. MATERIALS AND METHODS: In this retrospective cohort study, we included 40 condition-matched patients (8 patients per lesion) with chorditis, vocal nodules, vocal polyps, Reinke's edema (RE), or vocal scars who received similar regimens of steroid injection using a commercial preparation of triamcinolone acetonide. Their phonological outcomes were evaluated 2 or 3 months after the injection. RESULTS: Significant improvements were observed in Voice Handicap Index scores, results of laboratory voice evaluation, and voice quality measured using the Grade, Roughness, Breathiness, Asthenia, Strain scale in all participants. In subgroup analysis, VFSI was highly effective against chorditis and vocal nodules, but less effective against RE and vocal scars. CONCLUSIONS: Single-dose VFSI is valuable as an alternative to voice rehabilitation and laryngo-microsurgery, but higher concentrations or repeated injections are required for intractable lesions.