Paralytic Dysphonia Research Articles

Effect of Aging on Vocal Outcomes After Laryngeal Reinnervation Combined With Arytenoid Adduction

To evaluate the impact of aging on vocal function following laryngeal reinnervation combined with arytenoid adduction (AA) in the treatment of paralytic dysphonia. Sixty-eight patients with unilateral vocal fold paralysis who underwent refined nerve-muscle pedicle flap (NMP) implantation and AA were classified into four groups according to age: under 50 years (-50), in their 50s, 60s, and 70 years and older (70+). These groups consisted of 15, 14, 22, and 17 patients, respectively. Their vocal function was followed periodically for 24 months after surgery. Vocal function in all groups showed significant improvement after surgery. Significant improvements in vocal function were observed during a 24-month follow-up period: maximum phonation time in the -50 and 50seconds groups; pitch range and voice handicap index-10 in the -50, 50s, and 60s groups; "Grade" in the -50, 50s, and 70+groups; and "Breathiness" and voice-related quality of life in all groups. There were no significant differences in vocal function among the four groups, except for pitch range, at the 24-month postoperative assessment. Although the younger groups tended to exhibit better vocal function compared to the older groups 24 months postoperatively, the refined NMP+AA proved effective in the treatment of breathy dysphonia resulting from unilateral vocal fold paralysis, not only in the younger population but also in the older population.

Analysis of voice quality parameters in patients with vestibular voice.

Vestibular voice includes participation of larynx structures which are absent in physiological process. Vestibular phonation may be desired when vocal folds are damaged as in paralytic dysphonia, or undesired in marginal hyperfunction. Vestibular voice may result from psychogenic dysphonia - phononeurosis. The aim of the study is perceptive evaluation of vestibular voice, objective larynx visualization, acoustic and aerodynamic examination. The study included 40 patients: 20 with vestibular voice, 20 with euphonic voice. Voice quality has been evaluated using perceptual GRBAS scale. Endoscopic and stroboscopic larynx examination used Endo-STROB-EL-Xion GmbH with visual tract. High-Speed Digital Imaging (HSDI) and High Speed (HS) camera registered true vocal folds vibrations. Acoustic evaluation of voice with DiagnoScope Specjalista, DiagNova Technologies included analysis of F0, Jitter, Shimmer, NHR, nonharmonic components. MPT has been analyzed. In examined group, hoarseness (95%), roughness (75%) and voice strain (55%) have been recorded. Endoscopy revealed edema of vestibular folds with dilation of vessels covering glottis. Stroboscopy and HSDI confirmed coexistence of hyperfunctional (95%) or paralytic (5%) dysphonia. Acoustic assessment revealed increase in Jitter, Shimmer, NHR and decrease in F0 and MPT. The vestibular voice is observed most frequently in women with hyperfunctional dysphonia (phononeuroses) or in paralytic dysphonia. Visualization techniques confirm the coexistence of vestibular folds hypertrophy and edema with vibration disorders. In the perceptual assessment, vestibular voice was hoarse, rough and strained. Acoustic examination showed increase of Jitter, Shimmer, NHR, presence of nonharmonic components and decrease of F0 and MPT.

Certain modifications to simplify arytenoid adduction technique for correction of paralytic dysphonia

Certain modifications to simplify arytenoid adduction technique for correction of paralytic dysphonia

Sandwich Thyroplasty: A Novel Technique for Simplifying Medialization of Vocal Fold Using Silicone Implant in Paralytic Dysphonia with Modification of Thyroplasty Window

A novel technique of thyroplasty-Sandwich thyroplasty-described, with modification of Isshiki's thyroplasty window to overcome the problems of securing and stabilising the silicone implant in the window thus simplifying the medialization of the vocal fold. Seventy five patients diagnosed with paralytic dysphonia of varied etiology, attending Sri Sathya Sai Institute of ORL, Guntur, India from January 2005 to January 2012, were subjected to this new technique. Medialization of vocal fold was achieved by sandwiching and stabilising a silicone implant between a superiorly based cartilaginous hinged door and the inner perichondrium of the modified thyroplasty window. Results were analysed based upon pre and postoperative voice handicap index, maximum phonation time readings and video-stroboscopic findings. The results were statistically significant with no untoward complications. Sandwich thyroplasty technique facilitated easier fixation and stabilization of silicone implant avoiding difficult and time consuming, techniques involving flanges or sutures.

Laryngeal Muscle Activity in Unilateral Vocal Fold Paralysis Patients Using Electromyography and Coronal Reconstructed Images

To assess laryngeal muscle activity in unilateral vocal fold paralysis (UVFP) patients using laryngeal electromyography (LEMG) and coronal images. Case series with chart review. University hospital. Twenty-one patients diagnosed with UVFP of at least 6 months in duration with paralytic dysphonia, underwent LEMG, phonatory function tests, and coronal imaging. A 4-point scale was used to grade motor unit (MU) recruitment: absent = 4+, greatly decreased = 3+, moderately decreased = 2+, and mildly decreased = 1+. Maximum phonation time (MPT) and mean flow rate (MFR) were employed. Coronal images were assessed for differences in thickness and vertical position of the vocal folds during phonation and inhalation. MU recruitment in thyroarytenoid/lateral cricoarytenoid (TA/LCA) muscle complex results were 1+ for 4 patients, 2+ for 5, 3+ for 6, and 4+ for 6. MPT was positively correlated with MU recruitment. Thinning of the affected fold was evident during phonation in 19 of the 21 subjects. The affected fold was at an equal level with the healthy fold in all 9 subjects with MU recruitment of 1+ and 2+. Eleven of 12 subjects with MU recruitments of 3+ and 4+ showed the affected fold at a higher level than the healthy fold. There was a significant difference between MU recruitment and the vertical position of the affected fold. Synkinetic reinnervation may occur in some cases with UVFP. MU recruitments of TA/LCA muscle complex in UVFP patients may be related to phonatory function and the vertical position of the affected fold.

Laryngeal Muscle Activity in Unilateral Vocal Fold Paralysis Patients Using Electromyography and Coronal Reconstructed Images

Objectives: Assess laryngeal muscle activity in patients with unilateral vocal fold paralysis (UVFP) using laryngeal electromyography (LEMG) and coronal multi-planar reconstructed images (coronal images). Methods: Twenty-one patients suffering from paralytic dysphonia, who had had onset of UVFP more than 6 months previously, underwent LEMG, phonatory function, and coronal images. For LEMG analysis, a four-point scale was employed to grade motor unit (MU) recruitment; 4+: absent, 3+: greatly decreased, 2+: moderately decreased, and 1+: mildly decreased (less than full interference). Maximum phonation time (MPT) and mean airflow rate (MFR) were employed. Coronal images during phonation and inhalation were assessed focusing on differences in thickness and vertical position between the vocal folds during phonation. Results: MU recruitment results were three patients for 1+, five for 2+, six for 3+, and seven for 4+. MPT was positively correlated with the MU recruitments ( P = 0.011). The thinning of the affected fold was evident during phonation in 20 of the 21 subjects. All 8 subjects with MU recruitments 1+ and 2+ showed the affected fold located at an equal level to the healthy fold. Twelve of 13 subjects with MU recruitments 3+ and 4+ showed the affected fold located at a higher level than the healthy fold. There was a significant difference between MU recruitment and vertical position of the affected fold ( P = 0.001). Conclusions: MU recruitments in patients with UVFP may be related to phonatory function and the vertical position of the affected fold. Synkinetic reinnervation may occur in some cases with UVFP.

Implantation of Contralaterally Harvested Nerve‐Muscle Pedicle Flap Combined with Arytenoid Adduction for Paralytic Dysphonia

Objectives: 1) Describe operative procedures to reinnervate the thyroarytenoid muscle (TA) on the paralyzed side using a modified nerve-muscle pedicle (NMP) flap implantation harvested on the contralateral side combined with arytenoid adduction (AA). 2) Assess time-dependent improvement in vocal function during postoperative follow-up. Methods: Prospective case series. Four patients underwent modified NMP flap implantation combined with AA for paralytic dysphonia between August 2009 and January 2013. The NMP flap was harvested on the contralateral side because of scar formation on the paralyzed side and was secured to the TA under microscopic control. Three of them were followed over one year, and their voice outcomes, determined by 5 objective and 2 subjective parameters, were evaluated preoperatively and at 4 different time points after surgery. Results: On average, maximum phonation time and mean airflow rate improved from 5.4s and 569mL/s preoperatively to 24.2s and 116mL/s 12 months postoperatively, respectively. Jitter, shimmer, and harmonics-to-noise ratio also improved from 10.5%, 16.4%, and 4.2dB preoperatively to 1.7%, 11.2%, and 6.8dB postoperatively, respectively. Grade overall and breathiness of GRBAS scale became much better from 2.6 and 2.4 preoperatively to 0.2 and 0.0 12 months postoperatively, respectively. Stroboscopic images together with voice during follow-up period will be presented. Conclusions: Combination of AA and a modified NMP flap implantation harvested on the contralateral side improves long-term voice outcomes of paralytic dysphonia. Therefore, patients in whom the ansa cervicalis nerve is unavailable due to high level scar formation could have a great benefit by these operative methods.

Adduction arytenopexy, hypopharyngoplasty, medialization laryngoplasty, and cricothyroid subluxation for the treatment of paralytic dysphonia and dysphagia

Vocal fold paralysis is a common disorder of variable etiology. The resultant dysphonia and dysphagia can result in significant morbidity and decreased quality of life for the afflicted patient. Numerous surgical procedures have been developed to improve voice and swallowing, each with its own set of advantages and disadvantages. Selection of the most appropriate procedure is determined in part an assessment of the position of the arytenoid cartilage, as proper realignment of vocal fold height and length may be critical to restoration of phonatory function. While arytenoid adduction has been employed traditionally to address arytenoid position, adduction arytenopexy coupled with cricothyroid subluxation may provide enhanced aerodynamic efficiency compared to arytenoid adduction. Hypopharyngoplasty can be easily performed concurrently, which through plication of the flaccid and non-functional ipsilateral pyriform sinus, can provide significant improvement in the salivary pooling and dysphagia which often accompanies recurrent laryngeal nerve dysfunction. This paper will address the indications, advantages, and surgical technique of adduction arytenopexy, cricothyroid subluxation, and hypopharyngoplasty.

Zastosowanie nowoczesnych fizjoterapeutycznych metod rehabilitacji w leczeniu wybranych postaci dysfonii

Voice quality disorders – dysphonias are the significant problem from therapeutic, social and economic point of view. The routine therapy does not always bring spectacular effects. The important role play the innovative methods supporting therapy of voice quality disorders. PurposeThe aim of the study is to assess the effects of vibratory therapy of the larynx (Medical VR) in patients with hyperfunctional dysphonia and stimulating currents in phonatory exercises (VocaStim–Master) in paralytic dysphonia based on the analysis of parameters of objective assessment of voice quality. Material and methodsForty patients with hyperfunctional dysphonia treated routinely were included in the study. 20 patients apart from the routine therapy were additionally treated using the vibratory therapy of regions of the larynx (Medical VR, CyberBioMed LLC). In group of 40 patients with paralytic dysphonia, in 20 patients the adjuvant therapy by stimulating currents in phonatory exercises (VocaStim–Master, Physiomed) was used. The results of treatment and adjuvant therapy in hyperfunctional and paralytic dysphonia were analyzed based on: MPT, parameters of stroboscopic and acoustic evaluation (F0, Jitter, Shimmer, NHR) and narrow-band spectrography. Results and conclusions: The analysis of the results indicated the usefulness of used parameters of objective assessment of voice quality taking into consideration the diagnostic and therapeutic aspect in hyperfunctional and paralytic dysphonia. Adjuvant vibratory therapy of the larynx in hyperfunctional dysphonia and stimulating currents in phonatory exercises in paralytic dysphonia improved the effectiveness of the therapy, what was confirmed by the analysis of parameters of objective assessment of voice quality.

Vocal Outcome After Arytenoid Adduction and Ansa Cervicalis Transfer

To evaluate the long-term efficacy of arytenoid adduction (AA) combined with ansa cervicalis-recurrent laryngeal nerve anastomosis (ACN-RLN) in the treatment of unilateral vocal fold paralysis. Retrospective review of clinical records. Institutional practice. Nine patients with severe paralytic dysphonia with large glottal gap were included. Voice outcome was followed up over 24 months postoperatively. One patient did not attend the 24-month evaluation. All patients underwent AA + ACN-RLN. The ansa cervicalis nerve to the sternohyoid muscle was used as the donor nerve. Maximum phonation time (MPT), pitch range, harmonics-to-noise ratio (HNR), and perceptual voice quality were evaluated preoperatively and postoperatively at 1 to 3 months, 6 to 8 months, 12 to 14 months, and 24 months. All parameters improved significantly after surgery and continued to improve over the 24-month period. The MPT continued to improve over time (P = .01, P = .006, and P = .001 when comparing the 1- to 3-month evaluation with the 6- to 8-month, 12- to 14-month, and 24-month evaluations, respectively). Also, pitch range and HNR showed significant, steady improvement over the 24-month duration of the study. Perceptual voice quality markedly improved at 24 months compared with the 1- to 3-month, 6- to 8-month, and 12- to 14-month follow-ups (P = .004, P = .005, and P = .02, respectively, for grade overall, and P = .004, P = .008, and P = .02, respectively, for breathiness grade). Treatment with AA + ACN-RLN provides near-normal vocal function in the 24-month follow-up. Therefore, this method could be a successful surgical treatment for severe paralytic dysphonia.

Arytenoid rotation and nerve-muscle pedicle transfer in paralytic dysphonia

Our objective was to evaluate the efficacy of modified nerve-muscle pedicle (NMP) flap transfer combined with arytenoid adduction (AA) (AA + modified NMP) for treatment of unilateral vocal fold paralysis. The patterns of voice outcome assessed using phonatory function tests and auditory perceptual judgments were followed-up for 2 years. Prospective study. Thirteen subjects among those presented with paralytic dysphonia between March 2002 and December 2008 were treated with AA + modified NMP. The voice outcomes (six objective and two subjective voice parameters) were evaluated preoperatively and in four different time points postoperatively over 2-years duration. All voice parameters showed initial postoperative improvement. Moreover, five parameters showed significant continuous improvement over the 2-year follow-up (maximum phonation time, pitch range, shimmer, and grade overall and breathiness of the grade-roughness-breathiness-asthenia-strain scale (GRBAS), whereas two parameters revealed continuous improvement over the first 12 to 14 months after surgery (mean flow rate and harmonics-to-noise ratio). AA + modified NMP improves both short- and long-term voice outcomes in unilateral vocal fold paralysis patients. Therefore, AA + modified NMP is an effective surgical combination for the treatment of severe paralytic dysphonia.

Endoscopic Microflap Technique for the Management of Superficially Displaced Acellular Human Cadaveric Dermis During Injection Laryngoplasty

Injection laryngoplasty (IL), which has been practiced for more than a century, is a powerful, minimally invasive technique with the added potential of application in the outpatient setting. It has been advocated for the treatment of many laryngeal abnormalities that can result in symptomatic glottal incompetence. The recent increased attention to this procedure represents a resurgence of the laryngeal injection techniques that were widely touted in the 1960s and 1970s with the advent of polytef (Teflon) injection for paralytic dysphonia. Because several injectable dermal fillers, primarily designed for cosmetic uses, have since been developed, numerous new materials are currently available for vocal fold augmentation. Among them are micronized acellular human cadaveric dermis (Cymetra; LifeCell Corp, Branchburg, New Jersey), calcium hydroxylapatite, carboxymethylcellulose, and several products containing hyaluronic acid compounds. Newly described office-based, transnasal and percutaneous (thyrohyoid) routes for laryngeal injection have also been reported. 1,2 Despite all of these nuances of technique and injectable materials, the common technical pitfalls and complications of IL remain largely unchanged.

War, Politics, and Voice: The Vocal Fold Paralysis of George Orwell

In 1936, like many individuals who felt the menace of fascism, George Orwell traveled to Spain to lend his support to the cause of the Republic, battling a right-wing coup. Spain, during its Civil War, was an eye-opening experience for him, yielding insights that allowed, and even compelled him to write Animal Farm and 1984. Spain was also a close brush with death. In May of 1937, in a trench on a windswept ridge near Huesca, Orwell was shot through the neck by a sniper, leaving him with a paralyzed vocal fold. A thorough review of firsthand accounts of Orwell's injury and subsequent care was made. These are presented in the context of current knowledge of ballistics, penetrating neck trauma, and vocal fold paralysis. Orwell survived largely because of the nature of his wounding with a high-velocity jacketed military round. His recovery followed a course in many ways typical for patients with vocal fold paralysis. His writings leave us a unique and extraordinary account of the experience of being shot, of the medical care of the day, of the handicap of paralytic dysphonia, and of survival and heroism under extraordinary circumstances.

Laryngeal Reinnervation by Ansa Cervicalis Nerve Implantation for Unilateral Vocal Cord Paralysis in Humans

Ansa cervicalis (AC)-recurrent laryngeal nerve anastomosis (RLN) is usually not desirable for correction of paralytic dysphonia when it is difficult to find a viable distal stump of the recurrent laryngeal nerve. Nerve implantation of the thyroarytenoid muscle with the ansa cervicalis is a simple alternative method. Ten patients with unilateral vocal cord paralysis were prospectively designed to receive nerve implantation. A minimum period of 12 months after onset of paralysis was allowed to elapse to permit possible spontaneous reinnervation or compensation. Patients were followed long enough (at least 2 years) to determine if the procedure was successful. All patients were subjected to preoperative and postoperative voice recording, acoustic analysis, and videolaryngoscopy. Some of them underwent laryngeal electromyography. Ten patients underwent nerve implantation of the thyroarytenoid muscles by using the ansa cervicalis, and 8 of 10 (80%) had improved phonatory quality. Laryngeal electromyography showed that the procedure produced satisfactory reinnervation of the thyroarytenoid muscle. Nerve implantation of the thyroarytenoid muscle by the anso cervicalis is a simple and efficient alternative to nerve transfer if dense scarring at the cricothyroid articulation and lack of a viable distal stump of the recurrent laryngeal nerve preclude the procedure of nerve transfer. But careful selection of the appropriate candidate seems to be the earliest prerequisite for a successful procedure.

甲状軟骨形成術Ｉ型と披裂軟骨内転術の同時手術における筋突起の牽引方法について

Isshiki's arytenoid adduction combined with thyroplasty type I is a useful procedure for correcting the membranous vocal fold atrophy and the height difference between the two vocal folds, particularly in patients with a large posterior glottal chink and atrophy. Conventional arytenoid adduction (Isshiki's arytenoid adduction) is designed to place a suture through the muscular process of the arytenoid attached anteriorly to the thyroid ala, stimulating the function of the thyroarytenoid muscle and lateral cricoarytenoid muscle. Combining with thyroplasty type I, the suture direction of conventional arytenoid adduction prevented inserting implant material into the pocket of the thyroid cartilage window. In contrast to conventional arytenoid adduction, the suture direction in our approach is anchored anteroinferiorly, mimicking only the action of the lateral cricoarytenoid muscle (the major adductor of the larynx). It is used the thyroid cartilage window in thyroplasty type I to determine the direction of the lateral cricoarytenoid muscle. After approaching the muscular process based on Isshiki's arytenoid adduction, two nylon sutures are tied across the muscular process or the lateral cricoarytenoid muscle nearby the muscular process. The cricoarytenoid joint is not dislocated. One of the sutures was anchored to the inferior rear corner of the thyroid cartilage window to be used with thyroplasty type I and the other was anchored to the rear lower margin of the thyroid lamina. Gore-tex medialization thyroplasty is done after tying the sutures on the thyroid ala. Subjects were 30 unilateral paralytic dysphonia. Maximum phonation of all patients improved significantly after surgery. The preoperative and postoperative mean maximum phonation times were 6.0 and 17.9 seconds. No major complications occurred in this study. Our approach effectively combined arytenoid adduction and thyroplasty type I for patients with severe insufficient glottic closure.

Phonetic Effects of Paralytic Dysphonia

This study was performed to determine whether and how unilateral vocal fold paralysis (UVFP) affects the production and perception of voiced stop consonants as compared with unvoiced stops, and to analyze the phonetic effects of UVFP on the voicing feature. Phonetic constructs pronounced by 7 male patients with UVFP and 5 normal male subjects were recorded. The 432 speech tokens consisted of intervocalic, prevocalic, and postvocalic stop consonants (/p/, /t/, /k/, /b/, /d/, /g/) in the vowel contexts /a/ and /i/. Perceptual consonant identification testing was performed with 5 voice and speech professionals as listeners. The type and frequency of errors made in consonant identification were analyzed. Spectrographic analysis was used to analyze acoustic cues. The rate of correct consonant identification was significantly lower for tokens pronounced by patients with UVFP (77.3% versus 97.6%, p = .0001) because of incorrect identification of the voiced consonants, frequently perceived as their unvoiced homologues. Confusion between dental and alveolar place of articulation for unvoiced stops was also noted. Unilateral vocal fold paralysis alters the voiced-unvoiced stop consonant distinction and the dental-palatal stop consonant distinction in an experimental nonspeech context. This finding implies the existence of a phonetic handicap for patients with UVFP. Further studies should determine the effects of UVFP on global speech intelligibility.

Functional Significance of Arytenoid Adduction with the Suture Attaching to Cricoid Cartilage versus to Thyroid Cartilage for Unilateral Paralytic Dysphonia

In the treatment of unilateral paralytic dysphonia, traditional arytenoid adduction is designed to place suture through the muscular process of the arytenoid attaching anteriorly to the thyroid ala. In contrast with the suture direction of this technique, a new paramedian approach to arytenoid adduction anchors anteroinferiorly to the cricoid cartilage, mimicking the force action of the lateral cricoarytenoid muscle (the major adductor of the larynx). This study investigated the influence of these changes in suture direction on the vocal fold level as well as the vocal outcomes in these two techniques of arytenoid adduction. A prospective clinical series. Thirty patients with unilateral paralytic dysphonia underwent medialization laryngoplasty with arytenoid adduction and strap muscle transposition. Under local anesthesia, the thyroid lamina on the involved side was paramedially separated. The inner perichondrium was carefully elevated away from the overlying thyroid cartilage, carrying the dissection posteriorly to the level of the superior and inferior cornua. The lamina was retracted laterally, the inner perichondrium was opened near the midpoint, and the lateral cricoarytenoid muscle identified. Tracing the muscle fibers posterosuperiorly, the muscular process of the arytenoid was identified. A 2-0 Prolene suture was placed through the muscular process and temporarily tied to the anterolateral aspect of the thyroid ala (AA-thyroid suture). Intraoperative acoustic and perceptual assessments were performed. After releasing the tie, the suture was anchored to the cricoid cartilage at the origin of the lateral cricoarytenoid muscle (AA-cricoid suture). Voice assessments were repeated, and the outcomes of the two tests were compared. The choice of the type of arytenoid adduction suture was made intraoperatively according to which condition provided better vocal performance. After securing the suture, a bipedicled strap muscle flap was transposed into the space between the lamina and inner perichondrium and the thyroid cartilages sutured back into place. The intraoperative acoustic and perceptual assessments revealed the vocal performance was significantly better with AA-cricoid suture than the AA-thyroid suture in this series. No major complications occurred in the study. This study suggests that arytenoid adduction with suture attachment along the longitudinal axis of the lateral cricoarytenoid muscle to the cricoid cartilage is more physiologic and effective than that attaching the suture to the thyroid ala. A paramedian approach to arytenoid adduction with or without strap muscle transposition is a safe and effective method for treatment of unilateral paralytic dysphonia.

Vocal fold augmentation by autologous fat injection with lipostructure procedure

Fat is theoretically the ideal implant for vocal fold augmentation because it is soft, easily available and biocompatible. However, reabsorption is a frequent cause of long-term failure. We prospectively tested Coleman's "lipostructure" technique used for facial recontouring in the treatment of glottic incompetence. Fourteen patients (aged 18-74 years, mean 48) with breathy dysphonia secondary to laryngeal hemiplegia (7) or anatomical defects (7) underwent vocal fold lipoinjection. Fat harvested by liposuction was centrifuged, and the fat cell layer injected into the vocalis muscle. The patients underwent pre- and postoperative videolaryngostroboscopy, maximum phonation time (MPT) measurements, GRBAS perceptual evaluations, and Voice Handicap Index (VHI) self-assessments. Voice quality improved soon after surgery and remained stable over 3-26 months (mean 10.6), being confirmed by the GRBAS, MPT and VHI evaluations ( P < 0.005). The results were best in the seven patients with paralytic dysphonia. Lipostructure is a valuable technique for voice rehabilitation in glottic incompetence.

Spasmodic dysphonia: clinical features and effects of botulinum toxin therapy in 169 patients-an Australian experience.

Adductor spasmodic dysphonia (SD) is a focal laryngeal dystonia, characterised by strangled, effortful speech with breaks in pitch and phonation. Injection of laryngeal muscles with BTX is widely used in the treatment of SD. A consecutive series of 169 patients with SD, of whom 144 were treated with BTX injections, seen at St. Vincent's Hospital between 1983 and 1999 were studied prospectively. Patients underwent neurological, quantitative voice and otolaryngological assessment. Females (62.1%) outnumbered males (37.9%) and the mean age at diagnosis was 56 years (range 19-88). Adductor SD (89.4%) was more frequent than abductor SD (1.8%) or mixed SD (4.7%). Stridor was present in 14 patients (8.3%) and in 7 was the sole manifestation of the laryngeal dystonia. The median treatment outcome score was excellent in 63.2%, very good in 18.5%, satisfactory in 14.7% and unsatisfactory in 3.5%. Poorer treatment outcome was associated with abductor SD (OR = 4.69, CI [1.23, 17.92] p=0.024] and age >65 (OR = 2.83, CI [0.95, 8.42] p=0.049). Mild post-injection paralytic dysphonia was associated with longer lasting treatment (4.42 vs. 3.62 months p<0.001) and superior treatment outcome rating (1.37 vs. 1.81 p<0.001). We conclude that BTX injections are highly effective and severe adverse events are rare. Older age and abductor SD may confer a relatively poorer treatment outcome. Mild post-injection paralytic dysphonia may be a marker for more effective and lasting treatment in adductor SD.

Medialization laryngoplasty with Gore-Tex for voice restoration secondary to glottal incompetence: indications and observations.

Gore-Tex has been used as an effective implant for medialization laryngoplasty in the management of paralytic dysphonia; however, reporting of large patient cohorts has been limited. Furthermore, the use of Gore-Tex in the treatment of glottal incompetence secondary to soft tissue defects has not yet been described. Finally, a number of the procedural nuances of using Gore-Tex have not been elucidated. A prospective investigation was done on 142 patients who underwent 152 Gore-Tex medialization laryngoplasties in 183 vocal folds from December 1997 to March 2002. The primary diagnoses prompting the 152 procedures were paralysis in 94, paresis in 18, cancer reconstruction in 14, sulcus vocalis in 6, atrophy in 3, trauma defect in 5, arytenoid dislocation in 3, bilateral paralysis in 3, bilateral paresis in 1, parkinsonism in 4, and neurologic aerodynamic dissociation in 1. One patient who underwent reconstruction of a complex cancer defect required endoscopic removal of the Gore-Tex because of persistent granulation. Clinical observations reveal that Gore-Tex is a versatile implant that is ideally suited for phonosurgical reconstruction of aerodynamic glottal incompetence secondary to a variety of causes. Gore-Tex was especially useful for medialization of complex anatomic soft tissue defects such as those resulting from cancer resection, trauma, atrophy, and sulcus vocalis. There was superior ease in handling, placement, and in vivo adjustability.