Postoperative Voice Research Articles

Outcomes of Laryngeal Reinnervation for Unilateral Vocal Fold Paralysis in Children: Associations With Age and Time Since Injury.

Outcomes of laryngeal reinnervation with ansa-cervicalis for unilateral vocal fold paralysis (UVFP) may be influenced by age of the patient and time interval between laryngeal nerve injury and reinnervation, suggesting less favorable outcomes in older patients and greater than 2-year time interval after injury. This study examines these issues in the pediatric population. Review of prospectively collected data set of 35 children and adolescents (1-21 years) that underwent ansa-recurrent laryngeal nerve (RLN) laryngeal reinnervation for UVFP. The time from RLN injury to reinnervation averaged 5.0 years (range, 0.8-15.2 years). No correlation was found between age at reinnervation (r = 0.15) and patient- or parent-reported global percentage voice outcome or perceptual ratings. There was slight negative correlation in duration between RLN injury and reinnervation and voice outcomes (r = -0.31). Postoperative voice self/surrogate global percentage rating average was 80.5% (range, 50%-100%), and perceptual rating GRBAS sum score average was 2.9 (range, 0-7). In pediatric ansa-RLN reinnervation for UVFP, no correlation between age at surgery and postoperative outcome was found. Denervation duration showed slight negative correlation, similar to what has been reported in adults, though voice improvement was seen in all patients.

Effect of perioperative dexamethasone on subjective voice quality after thyroidectomy: a meta-analysis and systematic review

Prophylactic dexamethasone has been shown to reduce postoperative pain, nausea, and vomiting in patients undergoing thyroidectomy. However, its effects on postoperative voice outcomes remain uncertain. A systematic review and meta-analysis of the literature was conducted. Cochrane database, MEDLINE, EMBASE, and CINAHL were thoroughly searched. Studies that compared intravenous dexamethasone administration with no dexamethasone in patients undergoing thyroidectomy were included. Main outcome measure was the difference in postoperative voice assessment between groups. Standardized mean difference (SMD) and 95 % confidence intervals (CIs) were estimated using fixed and random effects models. Four studies with a total of 313 patients met inclusion criteria. Significant heterogeneity of study results was noted. Using random effects models, pooled data showed no difference in subjective voice quality between groups preoperatively (SMD, 0.29; 95 % CI -0.37 to 0.96; P = 0.39), 24 h after thyroidectomy (SMD, -1.02; 95 % CI -2.36 to 0.31; P = 0.13), or at 48 h (SMD, -0.05; 95 % CI -0.30 to 0.21; P = 0.72). A sensitivity analysis excluding one observational study yielded similar results. There are insufficient data for definite conclusions to be drawn regarding the effectiveness of a single perioperative administration of dexamethasone to reduce short-term voice disturbances after thyroidectomy. Further prospective trials using objective voice analysis are warranted to evaluate the efficacy of dexamethasone.

Thyroplasty in the previously irradiated neck: A case series and short-term outcomes.

External beam radiation to the neck is widely considered a contraindication for thyroplasty due to concern for infection and implant extrusion. We present a case series of our experience regarding thyroplasty performed in a previously radiated field. Retrospective case study at a tertiary academic referral center. Using the institution's clinical notes search tool, records from 1999 through 2014 documenting thyroplasty and radiation were identified and reviewed. Patients who received external beam radiation to the operative field prior to thyroplasty were included. Data including duration of radiation, timing and specifics of thyroplasty, postoperative complications, risk factors, clinical voice outcomes, and length of follow-up were collected. Fourteen patients met criteria for the study. Of all thyroplasty performed, 11 were Silastic implants, two were Gore-Tex implants, six had concurrent arytenoid adduction, and one was a midline type II thyroplasty. In terms of risk factors for postoperative complications, two were diabetic, none were active smokers, and one had a splenectomy. All patients were given postoperative antibiotics. The median duration of follow-up after surgery was 14.2 months. No patients were found to have postoperative complications. Pre- and postoperative voice data were assessed. Overall, there was improvement in voice outcomes. Thyroplasty may be an option for patients who have previously undergone external beam radiation. Short-term and intermediate outcomes in our patients showed no postoperative complications, and generally voice or dysphagia improved. Careful selection is still warranted when considering thyroplasty in a previously irradiated neck, and long-term outcomes need further study. 4 Laryngoscope, 126:1849-1853, 2016.

A comparative study of laser posterior cordotomy and vocal cord lateralization

IntroductionThe treatment of bilateral vocal cord paralysis continues to be a challenge to the otolaryngologist, head and neck surgeon even today. Numerous surgical procedures have been proposed to improve the patient’s airway insufficiency without leaving the patient with a breathy, weak voice or an incompetent larynx. In this study we compared the outcome of laser posterior cordotomy and vocal cord lateralization in a group of bilateral abductor palsy patients. MethodRetrospective as well as a prospective study of 25 patients was carried out. The total of 25 patients was divided into 2 groups, group 1 consisted of 15 patients who underwent vocal cord lateralization with SUTUPAK suture and group 2 consisted of 10 patients who underwent laser assisted posterior partial cordotomy. ResultsThyroidectomy was the commonest cause for bilateral vocal fold paralysis i.e. 80% (20) of cases. Patients who underwent laser posterior cordotomy had 100% successful decannulation rate as compared to 92.8% for vocal cord lateralization patients. Comparison between pre and post operative voice assessment data by WILCOXON SIGNED RANKS test revealed that excepting the parameter of fluctuations/s in F0, all other parameters were statistically not significant. ConclusionLaser cordotomy is a superior, reliable and viable alternative to the other lateralization procedures for bilateral vocal fold paralysis.

A prospective 1-year comparative study of transaxillary total thyroidectomy regarding functional outcomes: Is it really promising?

The purpose of this study was to evaluate postoperative voice outcomes and functional parameters in total thyroidectomy via a transaxillary (TA) approach. Seventy-six patients who underwent total thyroidectomy via a TA approach (TA group) were included. A total of 204 patients who underwent conventional open total thyroidectomy (conventional group) in the same time period were analyzed as a control group. All patients underwent prospective functional evaluations before surgery and at 1 week and 1, 3, 6, and 12 months postoperatively using a comprehensive battery of functional assessments. There was no conversion to conventional open thyroidectomy in the TA group. Operation time and the amount of drainage were significantly higher in the TA group than in the conventional group (p < 0.001 and p = 0.033, respectively), while vocal cord paralysis, hypoparathyroidism, and hematoma were not different among two groups (p = 0.215, 0.290, and 0.385, respectively). Regarding GRBAS, the TA group showed a more aggravated tendency postoperatively, although statistical significance was attained only at postoperative 6 months (p = 0.043). The voice handicap index abruptly increased postoperatively in the TA group, showing significant differences with the conventional group at postoperative 1 week and 1 month (p < 0.001 and p = 0.001, respectively). Fundamental frequency and maximal vocal pitch did not significantly change postoperatively in either group. The conventional group showed a more rapid decline in pain than the TA group, and paresthesias on the neck and chest were more aggravated in the TA group during the early postoperative period. The dysphagia handicap index was higher in the TA group, while cosmesis was better in the TA group at all postoperative periods. Although cosmetic outcome was better with the TA approach, the longer operation time, aggravated subjective voice outcomes, paresthesia, and swallowing function need to be considered in selecting the operative approach.

Hypernasality after using the endoscopic endonasal transsphenoidal approach for skull base tumors.

The increasing number of endoscopic endonasal transsphenoidal approaches (EETSA) has resulted in several sinonasal complications, including voice changes. Here, we compared preoperative and postoperative voice changes according to age. We retrospectively reviewed the medical records. Patients were divided into the following three groups according to age: ≤ 30 years, 31 to 60 years, and ≥ 60 years. Patients underwent preoperative voice evaluation using acoustic analysis, a nasometer, and the voice handicap index (VHI). A nasometer was used to measure the nasalance scores. The subjects read or repeated three speech stimuli. For each stimulus, mean nasalance scores were obtained and age dependence was analyzed. Repeat testing was performed 6 months postoperatively. One hundred and seventy patients who underwent binostril four-hand EETSA with a bilateral modified rescue flap were included in this study. Mean nasalance scores for the oral passage, oronasal passage, and nasal passage--as well as mean jitter scores, shimmer scores, and VHI--were significantly increased in all of the EETSA patients (P < 0.05 for all). Mean nasalance scores for the nasal sentences were significantly increased in the ≤ 30 age group (all, P < 0.05). Scores for the oronasal passage and nasal passage were significantly increased in the 31 to 60 age group (all, P < 0.05). Scores for the oronasal passage, nasal passage, jitter, and shimmer were significantly increased in the > 60 age group (all, P < 0.05). Endoscopic endonasal transsphenoidal approaches might contribute to voice changes. In addition, older age might produce hypernasality and roughness after EETSA. Patients who plan to undergo EETSA should be informed that their voice may change after the operation. 4.

Voice outcomes following reoperative central neck dissection for recurrent/persistent thyroid cancer.

We aimed to assess voice outcomes following reoperative central neck dissection (RCND) to characterize postoperative voice difficulties experienced, determine the natural progression of vocal recovery, and identify risk factors for the development of voice disorders postoperatively. Prospective cohort study. Consecutive patients with recurrent/persistent thyroid cancer who were deemed appropriate candidates for RCND were eligible for participation in this study. A battery of voice evaluation measures was administered both preoperatively and 2 to 4 weeks postoperatively. Twenty consecutive patients were included. Postoperatively, six (30%) new incidents of vocal fold motion impairment (VFMI) were identified, with two (10%) being due to intentional recurrent laryngeal nerve (RLN) transection. On 1-year follow-up, two patients had full restoration of vocal fold mobility and four had persistent VFMI. No preoperative voice/laryngeal exam factors were predictive of postoperative VFMI. Clinically relevant change in postoperative Voice Handicap Index score was absent in all patients without VFMI and present in five of six patients with VFMI (P=.0004). Patients with VFMI had significantly poorer overall dysphonia grade, less glottic closure, and elevated jitter in contrast to those individuals without VFMI. Patients with malignant tissue in the remnant thyroid were four times more likely to develop VFMI than those with central neck lymph node metastases alone (P=.06). Patients undergoing RCND are at risk for postoperative VFMI, even when the RLN is anatomically preserved, with subsequent impact on quality of life. Presence of malignant disease in the remnant thyroid appears to be the best predictor for postoperative VFMI. 2b.

Interdisciplinary Program in Sweden Related to Transgender Voice

Gender incongruence occurs when there is a discrepancy between gender identity and a person's sex assigned at birth and their bodily appearance. Sweden was the first country in the world to pass a law regulating a person's legal right to change gender. There are six psychiatric gender teams in Sweden responsible for diagnostic assessments and coordination of gender confirming medical interventions. Extended gender teams include endocrinologists, speech-language pathologists, phoniatricians, gynecologists, dermatologists, and surgeons. All male-to-female (MtF) and female-to-male (FtM) transgender individuals are referred for voice assessment when a gender dysphoria diagnosis has been confirmed. Voice assessment includes questionnaires and voice recordings in habitual and loud voice and voice range profiles. Voice and communication therapy is provided for both MtF and FtM individuals. Pitch-raising surgery can be considered and pre- and post-operative voice therapy is required for optimal results. The Swedish Association for Transsexual Health was launched 2004. The national guidelines were recently updated to make those more congruent with WPATH's Standards of Care version 7. A national quality registry for Gender Dysphoria has been accepted for financial support. The registry will in the future be a unique source to provide data concerning patient satisfaction, safety, and life quality.

Sex Differences in Pitch Range and Speech Fundamental Frequency After Arytenoid Adduction and Thyroplasty

The purpose of this study was to clarify the sex differences in pitch range (PR) and speech fundamental frequency (SFF) after arytenoid adduction (AA) combined with type 1 thyroplasty (TP1) in patients with unilateral vocal fold paralysis (UVFP) and to assess the cause of these differences. This is a retrospective review of clinical records. The records of 50 patients with UVFP for whom PR, SFF, and maximum phonation time (MPT) had been evaluated before and 1year after AA combined with TP1 were analyzed. Patients consisted of 36 men and 14 women. In particular, in the 37 patients (24 men and 13 women) who had ≥2 semitones (STs) in preoperative PR (pre-PR), the differences and correlations between the pre-PR and the postoperative PR (post-PR), SFF, and MPT were compared between the sexes. We also discussed cases of post-PR deterioration and abnormal SFF. The characteristics of PR in men are narrow pre-PR (14.7±11.5 STs) and significant extension of post-PR (22.6±6.3 STs). MPT extended from 4.6±2.5 seconds to 14.8±7.2 seconds. In contrast, women had a wide pre-PR (18.1±7.2 STs) and showed no significant post-PR extension (21.7±7.8 STs). MPT extended from 5.1±1.9 seconds to 16.8±7.2 seconds. Although there were no significant changes in average SFF, as well as the highest and lowest pitch after the operation, the variance of the pre-SFF tended to converge into the physiological range in the post-SFF (P=0.08). Compared with the SFF data of normal adult controls, post-SFF in the normal range was 46.0% (23/50). In patients who showed a >20% improvement in PR, normal post-SFF appeared in 68.8% of the patients (11/16). Particularly in those women, 83.3% (5/6) showed a normal post-SFF. Men showed greater difficulty in recovery of normal PR, SFF, and MPT; however, there were fewer patients (4.2%; 1/24) with a PR deterioration of >20%. Regarding women, although some patients showed a parallel recovery in PR and SFF to the normal range, there was a high rate of patients showing PR deterioration (30.8%; 4/13). AA combined with TP1 resulted in the recovery of not only MPT but also PR and SFF. In addition, sex differences in operative effects were suggested. In men, although MPT is difficult to be fully recovered, PR deterioration was mild. In women, although MPT was more easily extended, PR deterioration occurred more readily because of operative effects such as hypermedialization of their smaller larynx. The post-PR variation appeared to be associated with SFF. Our results indicate the necessity to assess patients' PR and SFF even if their MPTs recover, particularly in patients with postoperative voice insufficiency.

Comprehensive Outcome Researches of Intralesional Steroid Injection on Benign Vocal Fold Lesions

This study investigated multidimensional treatment outcomes, including prognostic factors and side effects of vocal fold steroid injection (VFSI). We recruited 126 consecutive patients, including patients with 49 nodules, 47 polyps, and 30 mucus retention cysts. All the patients received VFSI under local anesthesia in the office settings. Treatment outcomes were evaluated 1 and 2 months after the procedure, including endoscopic evaluation, perceptual voice quality (GRB scores), acoustic analysis, and 10-item Voice Handicap Index (VHI-10). More than 80% of the patients reported subjective improvements after VFSI. Objective measurements revealed significant improvements from baseline in most of the outcome parameters (P<0.05). Higher occupational vocal demands and fibrotic vocal nodules were significantly associated with poorer clinical responses as measured by the VHI-10 and GRB scores, respectively. For vocal polyps, dysphonia for more than 12 months were significantly associated with higher postoperative VHI-10 scores, whereas patients with laryngopharyngeal reflux (LPR) showed significantly poor postoperative voice quality as measured by GRB scores. Side effects after VFSI included hematoma (27%), triamcinolone deposits (4%), and vocal atrophy (1%), which resolved spontaneously within 1-2 months. Presentation with vocal fold ectasias/varicosities and higher vocal demands were significantly correlated with postoperative vocal hematoma. This study demonstrated significant improvements after VFSI in vocal nodules, polyps, and cysts. Occupational vocal demand and subtypes of vocal nodules are closely related to the treatment outcomes after VFSI, whereas symptom duration and LPR were significant prognostic factors for VFSI treatment outcomes in vocal polyps. Side effects after receiving VFSI were mostly self-limited without sequel, whereas the incidence rates might be varied by the injection approach and the timing for postoperative follow-up.

A prospective randomized controlled trial of the laryngeal mask airway versus the endotracheal intubation in the thyroid surgery: evaluation of postoperative voice, and laryngopharyngeal symptom.

The present study was performed to determine whether thyroidectomy patients undergoing general anesthesia provided with a laryngeal mask airway (LMA) have a lower risk of voice-related complications and laryngopharyngeal symptoms than those undergoing endotracheal intubation (ETI). In a prospective, double-blinded, randomized clinical trial, we studied 64 patients undergoing elective thyroid lobectomy between July 2013 and February 2014. Acoustic analyses were performed preoperatively and at 48 h and 2 weeks postoperatively. The voice handicap index (VHI), M.D. Anderson dysphagia index (MDADI), and laryngopharyngeal symptom score (LPS) were determined preoperatively and at 24 h, 48 h, 1 week, and 2 weeks post-thyroidectomy. In acoustic analysis, jitter, shimmer and noise-to-harmonic ratio showed significantly better results in the LMA group than the ETI group 48 h after surgery, but there was no difference at 2 weeks. The incidence of postoperative lower-pitched voice in the LMA group was also significantly lower than that in the ETI group. In the LMA group, the VHI, MDADI, and LPS were better compared to those in the ETI group at 24 h postoperatively, and improved to the preoperative state within 1 week. However, those in the ETI group remained poorer than the preoperative values 1 week after surgery. Use of the LMA in general anesthesia for thyroid surgery has advantages over the ETI in decreasing patients' subjective and objective voice symptoms, reducing the duration of symptoms, and relieving the laryngopharyngeal symptoms.

Documenting the Hypopharyngeal Environment of Patients Undergoing General Endotracheal Tube Anesthesia: A First Look at Intraoperative pH Characteristics

Objectives: While laryngeal injuries are important and not infrequent following both short and extended endotracheal tube exposure, little detailed information is available regarding the hypopharyngeal environment during intubation. The objective of this pilot study was to explore a simple method of accurately documenting hypopharyngeal pH values in surgical patients undergoing endotracheal tube anesthesia and to report the findings. Methods: Twenty volunteers were continuously monitored intra-operatively using a commercially available hypopharyngeal pH monitoring system. Demographics, pre- and postoperative voice and reflux self reported survey data were also collected. Results: No complications associated with the pH monitoring system occurred. Median pH was 6.5 (range 6.0-7.0); median recorded time in minutes was 183.9 (range 130.7 – 323.5). 13/20 patients had pH>5.0 ≤ 5.5 events, for up to 113 minutes of monitored time; 2/20 patients had pH>4.0 ≤ 5.0 events, for up to 8 minutes of monitored time; 2/20 patients had pH ≤ 4.0 events, for up to 61 minutes of monitored time. Conclusions: The hypopharyngeal pH test was used successfully to intra-operatively record hypopharyngeal pH variations. Extended pharyngeal exposures to low pH environments were commonly documented. No associations were found with patient survey scores. Future research appears warranted to expand this study, identify “at-risk” populations and to rigorously evaluate an expanded set of voice-related and lower airway clinical outcomes measures.

A Case of Horizontal Partial Laryngectomy for Laryngeal Trauma

Received August 11, 2013 Revised October 31, 2013 Accepted October 31, 2013 Address for correspondence Hyun Jun Hong, MD, PhD Department of OtorhinolaryngologyHead and Neck Surgery, Catholic Kwandong University College of Medicine, International St. Mary’s Hospital, 25 Simgok-ro 100beon-gil, Seo-gu, Incheon 404-834, Korea Tel +82-32-290-3051 Fax +82-32-290-3050 E-mail hyunjun.hong@gmail.com *Current affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Catholic Kwandong University College of Medicine, International St. Mary’s Hospital, Incheon, Korea Laryngeal trauma is rare compared to other head and neck traumas, but it occurs, it can be life threatening. As for treatment, a laryngeal fracture that involves displacement of cartilage or extensive injury requires appropriate surgical treatments. For severe laryngeal fractures, conservative management is usually preferred with placing a stent to prevent laryngeal stenosis. But the downside of placing stents in the larynx includes the risk of granulation and infection. In this report, the authors describe a 35-year-old patient, who was diagnosed with blunt laryngeal trauma and treated by Horizontal partial laryngectomy. The patient’s post-operative breathing and voice were fair, and airway stenosis did not occur afterwards. Korean J Otorhinolaryngol-Head Neck Surg 2015;58(2):120-3

Investigation of Type I Thyroplasty Using Titanium Implant

The aim of this study was to describe a new titanium thyroplasty medializing implant and evaluate its usefulness. Retrospective study of 9 male patients with severe unilateral vocal fold paralysis after aortic-aneurysm surgery who underwent type I thyoplasty with arytenoid adduction under general anesthesia. Preoperative and postoperative glottal closure and voice function were evaluated by acoustic analysis (Jitter %, Shimmer %, NHR), stroboscopic findings, maximum phonation time, mean airflow rate, voice handicap index and computed tomography findings. These tests were evaluated before and 3 months after surgery. All acoustic parameters improved after surgery. In stroboscopic findings, symmetrical mucosal waves were identified in 3 cases. Maximum phonation time prolonged, mean flow rate decreased and voice handicap index improved. In computed-tomography findings, breakage, deformation, dropped and migration of titanium plate were not identified. In surgery of vocal fold paralyzed patient, it is necessary to reconstruct vocal fold in physiological state at the time of phonation. Using the titanium plate developed for this purpose, all patients obtained good vocal improvement.

Preoperative and postoperative laryngoscopy in thyroid surgery

The absence of preoperative or postoperative voice change does not exclude RLN palsy; conversely, preoperative or postoperative hoarseness does not exclusively indicate RLN injury. Knowledge of preoperative vocal cord function is important to patient counselling for postoperative complications. It is also essential for the management of cases with thyroid carcinoma infiltrating the RLN since it facilitates preoperative recognition of disease extent, preoperative investigation planning and appropriate operative strategy. The value of routine preoperative and postoperative laryngoscopy in all patients undergoing thyroid surgery, however, is debatable in the literature. The recommendations of the Greek Association of Endocrine Surgeons suggest that preoperative laryngoscopy is required in symptomatic cases, reoperations or invasive thyroid malignancy, and postoperative laryngoscopy is necessary in symptomatic patients. Further studies, especially prospective randomized studies, are required in order to draw definitive conclusions.

Management of complications after thyroid surgery

The evolution of thyroid surgery has decreased the incidence of complications significantly. Experienced endocrine surgeons report less than 1% of complications. However, laryngeal nerve injury and hypocalcaemia still occur. Less common complications of thyroidectomy include postoperative bleeding, major thoracic duct injury, and even more rarely tracheal injury and oesophageal injury. In cases of postoperative voice change or hoarseness, the patient should be evaluated with direct laryngoscopy to define the extent of injury and the course of treatment. Steroids may be used. The patient should be followed up until complete resolution of nerve palsy. If the laryngeal nerve injury is considered permanent, operative treatment may be considered by referral centres with expertise. Swallowing studies and voice therapy should also be initiated. Post-thyroidectomy bleeding may be life-threatening and requires an emergency reoperation to decompress the upper airway. Injury of the major thoracic duct may be managed with either conservative or operative treatment based on the amount of daily lymphorrhea. Injury of the trachea and/or oesophagus usually requires surgical repair. The above complications require an immediate and stepwise therapeutic approach from the vigilant surgeon. Although the prevention of those complications remains the first goal of the surgeon, if such complications are encountered, the surgeon should implement the most appropriate intervention according to the above recommended management guidelines.

Treatment of Hemorrhagic Vocal Polyps by Pulsed Dye Laser-Assisted Laryngomicrosurgery.

Objective. Conventional surgical techniques of laryngomicrosurgery (LMS) on hemorrhagic vocal polyps are often difficult due to obscuration of the surgical field by inadvertent bleeding from the lesion, and there are often significant amounts of mucosal epithelium loss. Here, we introduce our surgical technique using pulsed dye laser (PDL), which can effectively resect the polyp with vocal fold mucosa preservation. Methods. Patients who were diagnosed with hemorrhagic vocal polyp and who were surgically managed using PDL from March 2013 to October 2014 were retrospectively reviewed. Preoperative and postoperative clinical outcomes and surgical findings were evaluated. Results. A total of 39 patients were treated with PDL-assisted enucleation LMS. The average age was 43.7 years (range 20–73), and there were 20 males and 19 females (17 professional voice users). In all cases, the hemorrhagic polyp was successfully enucleated after application of PDL, thereby preserving the overlying epithelium. Postoperative voice outcomes were favorable with clear preservation of the vocal fold mucosal wave. Conclusion. PDL-assisted enucleation LMS for the treatment of hemorrhagic vocal polyps can be a safe and effective surgical technique. It can be considered a promising treatment option for hemorrhagic vocal polyps.

Vocal fold pseudocyst: a prospective study of surgical outcomes.

To examine rates of lesion recurrence and functional impairment after surgical removal of vocal fold pseudocysts and determine factors predictive of recurrence. Prospective cohort study. Patients who underwent surgical removal of pseudocyst were recruited for 12 months of postoperative follow-up. A clinical consensus cohort of 10 laryngologists blindly reviewed pre- and postoperative videostroboscopic examinations to determine presence of pseudocyst and concurrent clinical variables (reactive lesion, varix, paresis). Patients completed a postoperative Voice Handicap Index-10 (VHI-10) and follow-up questionnaire. Results were analyzed to determine lesion recurrence rates, degree of postoperative functional impairment, and predictors of recurrence. Eighteen surgeries on 17 patients (15F:2M) with pseudocyst were examined. All underwent perioperative behavioral treatment. Lesion recurrence rates were 22% (per treating laryngologist) to 33% (per clinical consensus cohort). No demographic variables proved predictive of lesion recurrence. No clinical variables predicted recurrence, although there was suggestion of paresis as a contributing factor. Postoperative VHI-10 scores were within normal limits for all patients, but 12% of patients experienced recurrent functional impairment requiring further treatment. Most individuals (15/17) returned to normal voice use without limitation after surgery. Some individuals appear predisposed to lesion recurrence, which occurs relatively swiftly. Demographic features and clinical variables are not predictive of recurrence. The role of glottic insufficiency related to recurrence warrants further study.

Prospective randomized study on injury of the external branch of the superior laryngeal nerve during thyroidectomy comparing intraoperative nerve monitoring and a conventional technique.

The external branch of the superior laryngeal nerve (SLN) is susceptible to injuries during thyroidectomy, causing voice impairment. Intraoperative nerve monitoring may facilitate identification of the nerve, reducing voice impairment. A total of 252 patients undergoing thyroidectomy were randomly assigned to group N (the NIM-Response 3.0 system was used) or group C (the conventional technique using the Vari-Stim 3 was used) to identify the external branch of the SLNs. The primary endpoint was the identification rate of the external branch of the SLN. The secondary endpoint was the incidence of postoperative voice impairment. The visual and the electrostimulatory identification rates of the external branch of the SLN in group N and group C were 48.8% versus 17.8% (p < .001) and 89.2% versus 17.8% (p < .001), respectively. The proportion of female patients who had subjective voice impairment was significantly smaller in group N than in group C. The use of the NIM-Response 3.0 significantly improved the identification rate of the external branch of the SLN during thyroidectomy, reducing voice impairment.

CO2 laser cordectomy for glottic squamous cell carcinoma involving the anterior commissure: voice and oncologic outcomes.

Transoral CO2 laser cordectomy for squamous cell carcinoma (SCC) of the glottis has resulted in excellent voice and oncologic outcomes as compared with non-surgical therapy. However, published experience with primary CO2 laser cordectomy specifically for glottic SCC involving the anterior commissure (AC) is limited. A review of single academic institution experience with CO2 laser cordectomy for glottic SCC involving the AC. Patients undergoing European Laryngological Society (ELS) classification cordectomy type Va or type VI between 2005 and 2013 were included. Post-surgical voice analysis was performed by speech language pathologists (SLP) from the reporting institution. Thirty patients were identified for inclusion. Mean post-surgical follow-up time was 47.6 months (range 11-59). Initial local recurrence was identified in 5/30 (16.7%) patients. 2/5 recurrences were successfully salvaged by repeat CO2 laser resections, 2/5 ultimately required salvage total laryngectomy, and 1/5 patient developed a second primary preventing further curative treatment. Overall laryngeal preservation rate was 28/30 (93.3%). Overall survival of the study cohort was 96.7%. Mean postoperative voice handicap index-120 score was 36.9 (SD = 21.4). Perceptual analysis performed on the GRBAS scale resulted in mean scores: G = 2.1 (SD = 0.9), R = 1.3 (SD = 1.1), B = 1.6 (SD = 1.2). Though cancers involving the AC represent an aggressive subgroup of glottic SCC, CO2 laser cordectomy results in encouraging oncologic and voice outcomes without the need for further therapy in the majority of cases. Clinical trials are encouraged to further define optimal treatment recommendations for glottic SCC involving the AC.