Perceptual, aerodynamic and acoustic outcomes of surgical technique for sulcus vocalis patients: A systematic review and meta analysis.

BACKGROUND: Sulcus Vocalis (SV) is a voice disorder characterized by the parallel invagination of the vocal fold epithelium that adheres to the vocal ligament. This condition disrupts the vibratory function, leading to glottal incompetence, hoarseness, and vocal impairment. Despite various proposed surgical techniques, a standardized treatment approach remains elusive. METHODS: We conducted a comprehensive search across PubMed/Medline, Embase, Web of Science, Scholar, and the Cochrane Library for studies on SV treatment. The inclusion criteria comprised original studies comparing pre- and post-treatment vocal outcomes in SV patients, published in English. We excluded case reports, reviews, studies without continuous data, and patients with vocal scar/atrophy. RESULTS: Fifteen observational studies were included (361 patients, 53.73 % male, average age 41.64 years). 80 % of these studies employed self-reported outcomes, while 81.25 % analyzed acoustic/aerodynamic data. The follow-up period varied from 4 to 44 months. All techniques significantly improved Voice Handicap Index (VHI) scores (p < 0.001). Dissective and combined techniques exhibited greater reductions in VHI-30/10 (p < 0.001). Maximum Phonation Time (MPT) improved significantly across all techniques (p < 0.001), with dissective techniques demonstrating superior MPT outcomes (p < 0.001). Jitter improved significantly for dissective and injective techniques (p < 0.001), as did Shimmer for all techniques (p < 0.001). Notably, combined techniques displayed the most significant reductions (p < 0.001). CONCLUSIONS: Surgical treatments significantly improve subjective, aerodynamic, and acoustic outcomes in SV patients. Dissective and combined dissective/injective techniques appear to yield better perceptual and phonatory outcomes compared to injective techniques alone. Further research is necessary to establish the optimal treatment approach for SV.

Impact of Wendler glottoplasty on acoustic measures and quality of voice in transgender women: a systematic review and meta-analysis.

PURPOSE: Since new evidence regarding the impact of Wendler glottoplasty (WG) on the voice in transgender women became available in the literature in recent years, we aimed to perform an updated systematic review and meta-analysis to determine the actual safety and efficacy of WG in the process of vocal feminization. METHODS: PubMed, Embase, and Cochrane were searched for English-language articles published until July 4, 2023. Studies were found eligible if they evaluated the impact of WG on the acoustic-aerodynamic measures and quality of voice in transgender women. RESULTS: Twenty-three studies were identified. After exclusion of three studies due to incomplete data, 20 studies including 656 patients were included in the meta-analysis. After WG, there was a significant increase of fundamental frequency, speaking fundamental frequency, and lower limit of the frequency range (p < 0.001). Concurrently, a significant reduction of frequency range and maximum phonation time was observed (p < 0.001). No significant differences were found between the pre- and postoperative values regarding the Grade, Roughness, Breathiness, Asthenia, and Strain scale score (p = 0.339). The overall score in the Trans Woman Voice Questionnaire (TWVQ) significantly improved after WG (p < 0.001). CONCLUSIONS: WG is an effective voice feminization method in transgender women, associated with a high procedural success and low risk of postoperative complications. Significantly improved TWVQ score after surgery suggests its positive impact on the voice-related quality of life. Postoperative decrease of maximum phonation time and frequency range does not seem to significantly impact the effectiveness of voice production.

Voice Pitch Shaping and Genderization: New Needs of Cosmetic Phonoplastic Surgery.

Voices can convey content, emotion, and essential information about an individual's gender and social information. Closely related to gender identification and sexual attraction, voices also positively affect many psychological factors of individuals. Surgeries have evolved from treating congenital diseases to fulfilling an individual's aesthetic needs for voice. Voice shaping is emerging as the next cosmetic surgery hotspot after skincare and appearance and body shaping. This paper summarizes the development of voice pitch shaping and genderization procedures out of the cosmetic need. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

[Vocal fold polyps: modern possibilities of laser surgery in comparison with the use of cold microinstruments]. / Polipy golosovykh skladok: sovremennye vozmozhnosti lazernoi khirurgii v sravnenii s ispol'zovaniem kholodnykh mikroinstrumentov.

OBJECTIVE: To perform a comparative analysis of phonosurgical interventions, which were made using a 445 nm semiconductor laser or cold microinstrumentation in patients with «vocal fold polyp¼ diagnosis. MATERIAL AND METHODS: The number of surgical interventions equal 30 regarding vocal fold polyp was done in otorhinolaryngology clinic of Pavlov First State Medical University of St. Petersburg in the period from September 2021 yr. to September 2022 yr. The phonosurgical intervention was performed under the conditions of direct suspension microlaryngoscopy by Kleinsasser under general anesthesia using high frequency ventilation through an endotracheal catheter. Surgical interventions were carried out using a 445-nm semiconductor laser in pulsed mode for patients of the 1st group (n=15) and using microsurgical instruments for patients of the 2nd group (n=15). The comparative analysis was conducted based on the results of an objective vocal function assessment by acoustic analysis, as well as on the data of a subjective assessment of the voice using the questionnaire VHI-10rus. The severity of reactive inflammatory phenomena in the postoperative period has been compared and the oscillating movements of vocal folds have been evaluated according to the videolaryngoscopy data. The severity of pain syndrome in the postoperative period was assessed by visual analogue scale. RESULTS: There were no statistically significant differences in the results between two groups. Similarly, there were no statistically significant differences in parameter recovery degree, evaluated by videolaryngoscopy data. Moreover, a full recovery of mucosal wave was found in 93% of patients operated with laser on 7th day, while 47% of patients had the same result after use of cold microinstrumentation. CONCLUSION: The use of 445-nm semiconductor laser for phonosurgical interventions in vocal folds' polyps can be recommended for predicted successful recovery of vocal function, minimization of reactive inflammatory phenomena in postoperative period and early patients' rehabilitation.

Phonosurgery of Reinke's edema with microdebrider.

PURPOSE: To present our experience with a new microsurgical approach for treatment of the Reinke's edema in suspension laryngoscopy-microdebridement. After a short review of existing literature we introduce speech therapy before and after the surgery into the protocol. METHODS:  The authors compare the phonatory outcome, laryngostroboscopical results and subjective improvement of the voice of 30 patients with Reinke's edema that were operated with either microdebridement or cold steel surgery techniques. "Sandwich" speech therapy strategy was applied for the vocal rehabilitation before and after surgery in both patient groups. RESULTS: After the microdebridement and the speech therapy the mucosal wave was regular, symmetric and periodic in all patients. No signs of abnormal scar tissue or anterior adhesions were observed. Significant improvement of vocal parameters was found after the surgery in both groups of patients: operated with the microdebridement technique and the cold steel technique. The subjective voice evaluated by Voice Handicap Index (VHI-10) was improved for both patient groups in a homogenous way. CONCLUSIONS: Based on the similarity of the vocal outcome in the two groups, microdebridement of the vocal folds is an excellent method for removing the edema of the Reinke's space. Careful suction at a low voltage protects the lamina propria during the microdebridement. The authors discuss the indication to this innovating procedure in patients with difficult laryngeal exposure and small operating field.

The role of voice rest after micro-laryngeal surgery for benign vocal fold lesions.

PURPOSE: To compare post-operative vocal outcomes of a voice rest regimen versus no voice restrictions following micro-laryngeal surgery for benign glottic lesions. METHODS: This was a combined prospective and retrospective cohort study on 167 patients who underwent micro-laryngeal surgery for benign focal fold lesion removal. Participants were divided into two regimens: standard voice rest (n = 92) or no voice restriction (n = 75). The primary outcome was post-operative vocal improvement, evaluated using voice handicap index questionnaire (VHI-10), GRBAS scale, and computerised acoustic analysis (shimmer, jitter, and the harmonic-to-noise ratio). The secondary outcome was emergence of vocal fold mucosal abnormalities in the immediate post-operative period. Parameters were collected at baseline and at the last clinical visit. RESULTS: There was no statistically significant difference between the voice rest and no-voice rest groups regarding baseline parameters of age, gender, laryngeal pathology, and voice use. Improvement in GRBAS scale values and VHI-10 scores between pre- and post-operative periods between groups did not demonstrate any statistically significant differences (P = 0.5303 and P = 0.1457, respectively). Similarly, the results of computerized voice analysis also showed no differences between groups in terms of shimmer (P = 0.9590), jitter (P = 0.5692), and harmonic-to-noise ratio (P = 0.1871). No correlation was found between the post-operative vocal fold's mucosal abnormalities and the type of voice rest regimen. CONCLUSION: Voice quality and wound healing were similar regardless of the type of voice rest regimen applied. No voice rest at all was as good as voice rest after micro-laryngeal surgery.

Informed consent for suspension microlaryngoscopy: what should we tell the patient? A consensus statement of the European Laryngological Society.

INTRODUCTION: Informed consent for any surgical intervention is necessary, as only well-informed patients can actively participate in the decision-making process about their care, and better understand the likely or potential outcomes of their treatment. No consensus exists on informed consent for suspension microlaryngoscopy (SML). MATERIALS AND METHODS: Informed consent procedures in nine countries on five continents were studied. RESULTS: Several risks can be discerned: risks of SML as procedure, anesthesiologic risks of SML, specific risks of phonosurgery, risks of inadequate glottic exposure or unexpected findings, risks of not treating. SML has recognized potential complications, that can be divided in temporary (minor) complications, and lasting (major) complications. CONCLUSION: SML is a safe procedure with low morbidity, and virtually no mortality. Eleven recommendations are provided.

The Effect of Platelet-Rich Plasma Injection on Short Term Vocal Outcomes Following Phonosurgery-A Pilot Study.

Background and Objectives: The efficiency and optimal voice rest period following phonosurgery remains debatable. Platelet-rich plasma (PRP) is a safe and cheap alternative to many bioactive agents being studied on animal models, and is already in use in many medical areas. We investigate the short-term effects of PRP and voice rest on voice outcomes following phonosurgery as an alternative to voice rest alone. Materials and Methods: A prospective single-blinded pilot study was conducted. Sixteen patients with a diagnosis of vocal fold cyst and polyps were included, forming equal groups (PRP and voice rest vs. voice rest alone). Voice analysis was carried out on the preoperative day, day three, and week three following surgery. The measured parameters were fundamental frequency (F0), noise-signal ratio (NSR), harmonic poverty (HP), attack alteration (AL), pitch instability (PI), and amplitude instability (AI).VHI(Voice Handicap Index)-30 questionnaires were carried out before surgery and three weeks following surgery to assess the impact of subjective voice change on quality of life. PRP was obtained using commercial kits with separator gel. Results: An average 3.68-fold increase in platelets was obtained with PRP. No side effects were noted after injection. All voice parameters improved on day three and week three following surgery. Statistical significance was noted only in the fundamental frequency of male patients (p = 0.048) in favor of the PRP-voice rest group. In addition, the VHI- 30 questionnaire results between preoperative and postoperative assessments showed statistically significant differences in total VHI score (p = 0.02) as well as the physical (p = 0.05) and emotional (p = 0.02) scale in favor of the PRP-voice rest group. Conclusions: PRP presents short term safety in patients who undergo phonosurgery, although long-term outcomes are unknown. PRP and voice rest are superior to voice rest alone when considering subjective assessment of the voice. When analyzing acoustic parameters, PRP and voice rest are not superior to voice rest alone.

Gender Affirming Laryngeal and Voice Surgery.

Gender affirmation laryngeal and voice surgeries are components of "voice-lift" or cosmetic voice surgeries. Feminization surgery can modify vocal folds (fundamental frequency [Fo]) and vocal tract (resonance frequency). For increased pitch, vocal folds should be shorter, thinner, and tighter. Cricothyroid approximation (CTA) surgery increases tension of the vocal folds. Endoscopic procedures for pitch raising are done by shortening the length and reducing mass of vocal folds. This shortening is achieved by surgically creating anterior glottic web. Comparing the results of various open and endoscopic surgical techniques, fundamental frequency (Fo) is raised maximally and remains stable after GL as compared with CTA.

Phonosurgery Training in Human Larynx Preserved with Thiel's Embalming Method.

BACKGROUND: To describe the suitability of larynges preserved with Thiel's embalming method for phonosurgery training. METHODS: A training model for phonosurgery techniques simulating vocal pathology and glottal insufficiency is developed to compare and evaluate the perception of embalmed vocal cords through a voluntary and anonymous survey rated on a scale of 1-5. A total of 10 residents and young otolaryngologists participated in the surgical training in phonosurgery. RESULTS: Ten larynges preserved in formalin and 10 Thiel's embalmed larynges were used for the investigation. Phonosurgery procedures were performed following microflap and injection laryngoplasty techniques. The larynges preserved with Thiel's method demonstrated vocal cords that maintain their pliability and good tissue quality allowing a sensation of realism compared to the living body and providing suitable conditions for realistic laryngeal training. Participants held a positive experience, believed them to be useful and that these models of embalmed larynges were similar to the clinical setting and improved skills and confidence in performing phonosurgery. CONCLUSIONS: The human larynges embalmed with Thiel's method maintain the pliability of the vocal cords, thus representing a unique model to practice and reproduce training for endolaryngeal procedures without the risks of contamination, anatomical variation, or rigidity of other models.

[Laryngeal framework surgery]. / "Laryngeal framework surgery".

Laryngeal framework surgery is an umbrella term for all phonosurgical procedures by which the cartilaginous structure of the larynx and thereby the position and tension of the vocal folds are changed. The aim is to improve the voice. By far the best known and most frequently performed operation is thyroplasty type 1 according to Isshiki, also known as medialization thyroplasty, which is indicated for treatment of glottic insufficiency. Although the first medialization thyroplasty was successfully performed by Payr in Germany in 1915, more than 100 years later, it is still not widely used in Germany.

[Voice diagnostics in phonosurgical interventions]. / Stimmdiagnostik bei phonochirurgischen Eingriffen.

Voice diagnostics before and after phonosurgical interventions should aim at detailed planning of surgical techniques and evaluability of postoperative outcome. They should consider multimodal concepts and include measurements of perceptual voice analysis, laryngostroboscopy, voice acoustics, aerodynamics, and self-evaluation by the patients. Selected methods for voice diagnostics should reflect current knowledge and define the departmental procedure.

[Update on vocal fold augmentation]. / Update Stimmlippenaugmentation.

Unilateral vocal fold palsy is a frequent cause of hoarseness. In the presence of glottis closure insufficiency, the effectiveness of conservative voice therapy is often limited and phonosurgery may be indicated. Injection laryngoplasty is effective for correction of insufficiency. Early intervention during the first 6 months after diagnosis is desired to avoid subsequent insufficient endogenous compensation. Particularly patients with glottic closure insufficiency ≤2 mm in stroboscopy may benefit from this procedure. With appropriate patient selection, duration of the effect exceeding 12 months has been described for hyaluronic acid, calcium hydroxylapatite, and autologous fat. Due to rare complications such as allergic swelling at the injection site, regular laryngoscopic monitoring and observation for two nights after injection are recommended. The voice must only be rested for a few hours.

ELS live surgery: a developing story.

INTRODUCTION: Since 2015, the European Laryngological Society (ELS) has organized on a yearly basis the European Laryngological Live Surgery Broadcast. The goal of this paper is to demonstrate the increasing worldwide audience. MATERIAL AND METHODS: The number of individual computers logged in, number of estimated audience, and number of countries with an active audience were calculated and compared to the numbers in 2015. RESULTS: In 2018, 19 live interventions were performed in three parallel sessions. The surgeons worked in 10 departments in 8 different countries. The number of individual computers logged in increased from 1000 in 2015 to 16000 in 2018. The estimated audience increased from 3000 to 32000 visitors. The number of countries with an active audience increased from 52 to 91. DISCUSSION: The amount of computers logged in is increasing year by year. The audience was presenting despite inconvenient broadcasting times, highlighting the educational importance. The teaching aspect remains visible on videos of this year's and previous year's interventions. They can be seen on website http://els.livesurgery.net/home.php . The organization of the European Laryngological Live Surgery Broadcast concurs to the idea that live broadcast of laryngologic surgery is feasible and attractive. Therefore, the ELS is going to continue to organize additional European Laryngological Live Surgery Broadcasts in the future.

Voice rest and sick leave after phonosurgical procedures: surveys among European laryngologists and phoniatricians.

PURPOSE: After surgery of vocal folds, almost every patient will need some voice rest. It is common to recommend total silence for some days, followed by less restricted voice use for variable periods. By now, we do not know how voice rest affects the healing process or the current practise in Europe. METHODS: Members of the European Laryngological Society (2012) and the Union of European Phoniatrics (2018) were sent a web-based questionnaire which included two patient cases with a short history and a still picture. The respondents were asked about the postoperative recommendation of absolute voice rest and sick leave. RESULTS: Over 90% of the respondents would recommend absolute voice rest after removing a polyp or after mucosal repair of Reinke's oedema. For both cases, the mean length of recommended absolute voice rest among UEP members was 4 days (range 0-10 days) and among ELS members was 5 days (range 0-14 days). The recommended sick leave ranged from 0 to 35 days. The mean figures suggested by ELS members for the receptionist with Reinke's oedema were 12 days and for the teacher with a polyp 13 days. On average, UEP members recommended 14 days of sick leave for both cases. CONCLUSION: The present scientific evidence is scant, but does not support for prolonged (over 3 days) absolute voice rest after simple phonosurgery. So far, there are no studies that could show absolute voice rest to be superior over relative voice rest. According to the present survey, there is considerable variation in recommending voice rest and sick leave after the removal of benign mucosal lesions. Many European laryngologists suggest voice rest that is longer and stricter than the present scientific literature supports.

A questionnaire using vocal symptoms in quality control of phonosurgery: vocal surgical questionnaire.

BACKGROUND: Quality control after phonosurgery is important and may be time consuming. Often questionnaires focusing on quality of life are applied. We aimed at investigating the use of organ specific symptoms, such as hoarseness and voice failure with the use of self-reported visual analogue scales (VAS) and Likert-scales. METHODS: A vocal surgical questionnaire using VAS and Likert-scales for hoarseness, voice failure and factors that could influence voice quality was given twice consecutively to a group of healthy volunteers (n = 57, 45 female) and a group of voice patients (n = 34, 21 females) for a test/re-test study. Secondly, a group of patients undergoing surgery (n = 90, 61females) answered the questionnaire preoperatively and postoperatively. The difference between test/retest, healthy volunteers and patients, and between pre- and postoperative results were compared. RESULTS: There was no significant difference in the test/retest results in healthy volunteers nor in the patient group. There was statistically significant difference between the healthy volunteers and patients, and between the preoperative and postoperative results after phonosurgery. CONCLUSION: This short and organ specific questionnaire clearly demonstrates the effect of phonosurgery, making it an easy and relevant tool in quality control and potentially reducing the need of postoperative controls in the outpatient clinic.

Preliminary experience in transoral laryngeal surgery with a flexible robotic system for benign lesions of the vocal folds.

PURPOSE: This purpose of this case series is to present the first four cases utilizing micro-phonosurgical instrumentation designed specifically for use with a semi-flexible 'robotic' system-the Medrobotics Flex system and to evaluate the accessibility and feasibility of this platform in the context of transoral robotic surgery (TORS) for laryngeal surgery. METHODS: Four patients (3 female, 1 male; age range 49-79 years) were operated by the senior author at CHL-a tertiary hospital centre between 2016 and 2017. The 'robot' was deployed in all cases to assess its accessibility and ability to perform surgery in the larynx. RESULTS: All four patients were successfully treated using the system along with newly developed instrumentation specifically focused on phonosurgery. CONCLUSION: This series has demonstrated accessibility and ability for laryngeal surgery using a novel semi-rigid operator-controlled 'robotic' system. We encountered no device failures and were able to perform all the selected cases uneventfully.

New 445 nm blue laser for laryngeal surgery combines photoangiolytic and cutting properties.

BACKGROUND: Photoangiolytic lasers have broadened the surgical armamentarium for many phonosurgical interventions. However, the pulse dye laser and potassium titanyl phosphate (KTP) laser have technical drawbacks and a smaller spectrum of indications. METHODS AND RESULTS: The new 445 nm wavelength laser, the so-called 'blue laser', proves to show tissue effects comparable to the KTP laser and is also capable of treating subepithelial vessels due to its photoangiolytic properties, it can coagulate and carbonize at higher energy levels, and can be used via glass fibers in non-contact and contact mode for in-office procedures. DISCUSSION: In contrast to the KTP, the new 445 nm laser can also be used as a cutting laser, thus combining very much wanted properties of diode or CO2 lasers with photoangiolytic lasers. Further advantages of the new laser are the; (1) portability of the shoe box sized, shock-proof laser machine for in-office and operating room usage, (2) the selection of pulse rates from continuous wave (cw) to less than a millisecond, (3) stronger tissue effects compared to KTP with similar energy and pulse settings, (4) far better cutting properties than the KTP, and thus (5) more possibilities for usage in laryngology as well as in other fields or surgery. CONCLUSION: We demonstrate the feasibility of the 445 nm laser in several laboratory experiments and show clinical cases where photoangiolysis and cutting was possible. However, this is a preliminary report and further systematic studies in greater numbers are warranted.

Videolaryngoscopy during Conscious Sedation in Patients Not Suitable for Phonosurgery by Microlaryngoscopy: A Pilot Study.

BACKGROUND: Microlaryngoscopy is the preferred and most widely used technique in phonosurgery for the treatment of benign and early malignant glottic lesions. However, the procedure may be technically difficult or impossible due to alterations of the cervical spine that may not allow hyperextension of the head or may present general anesthesia contraindications. The aim of this study is to evaluate the efficacy and safety of our surgical approach for lesions of the vocal folds in patients who are not suitable for phonosurgery by microlaryngoscopy. This approach applies videolaryngoscopy during conscious sedation, which combines local anesthesia with moderate analgosedation by using midazolam and fentanyl with premedication. METHODS: A total of 235 patients affected by benign diseases or suspicious cancerous lesions of the vocal folds were retrospectively evaluated. RESULTS: The method has shown a success rate of 95.5, 89, 52.3, and 86.7% in cases of polyps of the vocal folds, Reinke's edema, cysts of the vocal folds, and suspicious lesions of the larynx, respectively. Only 3 patients (1.27%) have been reported to experience adverse events. CONCLUSION: The results suggest that the method is an effective and safe procedure without relevant local and/or general complications.

[Phonosurgery treatment options in male to female and female to male transsexuals.] / Fonochirurgiczne metody leczenia glosu u pacjentów transseksualnych.

The voice is an important part of human identity. The voice is susceptible to impact of hormons mainly sexual hormons. The larynx is one of secondary sex characacteristics. Disorders of voice pose serious obstacle to full social integration in male to female and female to male transsexuals. The causes of transsexuality are still a matter of considerable debate. Now it is considered that, big nucleus suprachiasmaticus in the hypothalamus may be a cause of transsexuality. The aim of phonosurgery in transsexual patients is to gain acceptable voice by the patients. Proper preoperative assessment by the use of HRCT 3D imaging of the larynx and phoniatric counseling yields realistic postoperative results and verify patients expectations.