Postoperative Voice Research Articles

Compliance and Quality of Life in Patients on Prescribed Voice Rest

To determine patient compliance with voice rest and the impact of voice rest on quality of life (QOL). Prospective. University hospital. Demographics, self-reported compliance, QOL impact on a 100-mm visual analog scale (VAS), and communication methods were collected from 84 participants from 2 academic voice centers. Of 84 participants, 36.9% were men, 63.1% were women, and 64.3% were singers. The mean age of participants was 47.2 years. The mean duration of voice rest was 8.8 days (range, 3-28), and the median was 7 days. Overall compliance was 34.5%. Postoperative voice rest patients were more compliant than non-postoperative patients (42.4% vs 16.0%, P = .04, χ(2)). Voice rest had an impact on QOL (mean ± SD, 68.5 ± 27.7). Voice rest also had a greater impact on singers than nonsingers (mean VAS 77.2 vs 63.6, P = .03, t test) and on those age <60 years than those age ≥ 60 years (mean VAS 74.4 vs 46.7, P < .001, t test). More talkative patients and those with longer periods of voice rest had worse QOL scores (Spearman correlation = 0.35, P = .001 and Spearman correlation = 0.24, P = .03, respectively). Restrictions in personal and social life were noted in 36.9% of patients, 46.4% were unable to work, 44.0% felt frustrated, and 38.1% reported feeling handicapped while on voice rest. Given poor patient compliance and the significant impact of voice rest on QOL, further studies are warranted to examine the efficacy of voice rest and factors that may contribute to patient noncompliance with treatment.

Tracking voice change after thyroidectomy: application of spectral/cepstral analyses

This study evaluates the utility of perioperative spectral and cepstral acoustic analyses to monitor voice change after thyroidectomy. Perceptual and acoustic analyses were conducted on speech samples (sustained vowel /ɑ/ and CAPE-V sentences) provided by 70 participants (36 women and 34 men) at four study time points: prior to thyroid surgery and 2 weeks, 3 months and 6 months after thyroidectomy. Repeated measures analyses of variance focused on the relative amplitude of the dominant harmonic in the voice signal (cepstral peak prominence, CPP), the ratio of low-to-high spectral energy, and their respective standard deviations (SD). Data were also examined for relationships between acoustic measures and perceptual ratings of overall severity of voice quality. Results showed that perceived overall severity and the acoustic measures of the CPP and its SD (CPPsd) computed from sentence productions were significantly reduced at 2-week post-thyroidectomy for 20 patients (29% of the sample) who had self-reported post-operative voice change. For this same group of patients, the CPP and CPPsd computed from sentence productions improved significantly from 2-weeks post-thyroidectomy to 6-months post-surgery. CPP and CPPsd also correlated well with perceived overall severity (r = −0.68 and −0.79, respectively). Measures of CPP from sustained vowel productions were not as effective as those from sentence productions in reflecting voice deterioration in the post-thyroidectomy patients at the 2-week post-surgery time period, were weaker correlates with perceived overall severity, and were not as effective in discriminating negative voice outcome (NegVO) from normal voice outcome (NormVO) patients as compared to the results from the sentence-level stimuli. Results indicate that spectral/cepstral analysis methods can be used with continuous speech samples to provide important objective data to document the effects of dysphonia in a post-thyroidectomy patient sample. When used in conjunction with patient's self-report and other general measures of vocal dysfunction, the acoustic measures employed in this study contribute to a complete profile of the patient's vocal condition.

New technique for the treatment of bilateral vocal cord paralysis: Vocal and ventricular fold lateralization using crossing sutures with thyroplasty technique

Conclusion: All patients treated with this new lateralization technique had a good quality of life and no dyspnea at rest or upon exertion. We believe that this technique is an important addition to the many surgical techniques for the treatment of bilateral vocal cord paralysis (BVCP). Objectives: Most techniques used in the treatment of BVCP result in a prolapse of the laryngeal soft tissues into the endolarynx owing to Bernoulli's principle. We have developed a new lateralization technique to more effectively prevent this prolapse. Methods: The lateralization was initially tested on six cadaver larynges before being performed in five clinical cases with BVCP, who suffered from dyspnea at rest. Average follow-up was 17.6 months. As in type 1 thyroplasty, a rectangular piece of cartilage was excised horizontally from the thyroid lamina and placed on the defect in the vertical plane. Then, the vocal and ventricular folds were lateralized with crossing sutures, particularly in the posterior region. Results: Dyspnea was eliminated postoperatively. All patients were successfully decannulated. Postoperative voice quality was socially acceptable. Airways were improved postoperatively, as evaluated via fiberoptic laryngoscopy and CT. The mean preoperative and postoperative rima openings were 1.3 mm (range 0.5–2.6) and 6.4 mm (range 3.4–8.1), respectively.

Hydroxyapatite versus titanium implant: Comparison of the functional outcome after vocal fold medialization in unilateral recurrent nerve paralysis

Results of medialization thyroplasty for treatment of unilateral vocal fold paralysis are often unsatisfactory. This study compares glottal closure and voice quality after use of 2 different medialization implant types: VoCoM and TVFMI. In all, 26 patients with unilateral vocal fold paralysis following thoracic surgery underwent medialization thyroplasty. In 11 patients (group I), a hydroxyapatite implant (VoCoM) was used. In 15 patients (group II), a titanium implant (TVFMI) was used. Preoperative and postoperative glottal closure and voice function were assessed with videostroboscopy, perceptual and objective voice measures, and the Voice Dysfunction Index (VDI). Group II showed a higher rate of complete glottal closure and greater improvement in perceived hoarseness, maximal phonation time, and maximal voice intensity than those in group I. With the individually adjustable titanium implant, better glottal closure and better functional outcome (phonation time and voice quality) were achieved.

Coblation removal of laryngeal Teflon granulomas

AbstractLaryngoscope, 2010

Recurrent laryngeal nerve and voice preservation: routine identification and appropriate assessment – two important steps in thyroid surgery

The aims of this study were to assess and compare vocal cord functions before and after thyroid surgery after intra-operative identification of recurrent laryngeal nerve. Recurrent laryngeal nerve (RLN) is seen intra-operatively in all cases undergoing thyroid surgeries. Vocal cord functions including any voice change were evaluated by indirect laryngoscopy (I/L) and direct laryngoscopy (D/L) before and after surgery. Prospective study on 100 patients over 18 months with a total of 146 nerves at risk (NAR). Majority were women (n = 86) with mean age of 37.48 years (range, 13-60 years). RLN was seen in all patients and 19 patients complained of some change in quality of their voice after surgery. Evaluation by I/L and D/L at 6 weeks showed recurrent laryngeal nerve palsy (RLNP) in nine (47.36%) and five (26%) of these 19 patients respectively. Analysed according to total NAR, the incidence of voice change and temporary RLN palsy (I/L and D/L) at 6 weeks was still less at 13.01%, 6.16% and 3.42%, respectively. Voice change improved in all cases at 3 months with no RLNP palsy by I/L or D/L. All these 19 patients had undergone difficult or extensive surgery for malignancy, large gland, extratyhroidal spread or fibrosis. Despite identification and preservation of RLN, patients can develop postoperative voice change and RLNP although all voice change cannot be attributed to damaged RLN. Proper assessment of vocal cord functions by I/L and D/L laryngoscopy is required to rule out injuries to these nerves. Risk of damage is higher in patients undergoing more difficult surgery.

Laryngeal Mask Airways Have a Lower Risk of Airway Complications Compared With Endotracheal Intubation: A Systematic Review

The purpose of the present study was to determine whether, in patients undergoing general anesthesia, those provided with a laryngeal mask airway (LMA) have a lower risk of airway-related complications than those undergoing endotracheal intubation. A systematic review of randomized prospective controlled trials was done to compare the risk of airway complications with an LMA versus an endotracheal tube (ETT) in patients receiving general anesthesia. Two independent reviewers identified 29 randomized prospective controlled trials that met the predetermined inclusion and exclusion criteria. The data for each individual outcome measure were combined to analyze the relative risk ratios (RRs). The Cochrane RevMan software was used for statistical analysis. When an ETT was used to protect the airway, a statistically significant greater incidence of hoarse voice (RR 2.59, 95% confidence interval [CI] 1.55 to 4.34), a greater incidence of laryngospasm during emergence (RR 3.16, 95% CI 1.38 to 7.21), a greater incidence of coughing (RR 7.12, 95% CI 4.28 to 11.84), and a greater incidence of sore throat (RR 1.67, 95% CI 1.33 to 2.11) was found compared with when an LMA was used to protect the airway. The differences in the risk of regurgitation (RR 0.84, 95% CI 0.27 to 2.59), vomiting (RR 1.56, 95% CI 0.74 to 3.26), nausea (RR 1.59, 95% CI 0.91 to 2.78), and the success of insertion on the first attempt (RR 1.08, 95% CI 0.99 to 1.18) were not statistically significant between the 2 groups. For the patients receiving general anesthesia, the use of the LMA resulted in a statistically and clinically significant lower incidence of laryngospasm during emergence, postoperative hoarse voice, and coughing than when using an ETT. The risk of aspiration could not be determined because only 1 study reported a single case of aspiration, which was in the group using the ETT.

Severe laryngeal fracture treated by supracricoid laryngectomy

To report a rare case of severe laryngeal fracture treated by supracricoid laryngectomy. Previously, a few cases of major laryngeal trauma treated by reconstructive laryngectomy have been briefly described. This paper aims to comprehensively document a rare case of severe laryngeal fracture for which this difficult treatment choice represented an acceptable option. A 33-year-old woman sustained very serious blunt laryngeal trauma. The complexity of the laryngeal injuries led us to opt for supracricoid laryngectomy, rather than to attempt laryngeal repair. The post-operative course was normal. The patient's post-operative voice was breathy but functional. No airway stenoses occurred. For severe laryngeal fractures, reparative procedures and stenting constitute the standard treatment. However, in selected and especially critical cases, a primary partial or reconstructive laryngectomy is justifiable.

Endoscopic Laser Anterior Commissurotomy for Anterior Glottic Web: One-Stage Procedure

The conventional method for preventing web formation after anterior glottic web surgery is keel insertion. However, this presents risks of airway compromise and granulation tissue formation, which could necessitate tracheotomy in addition to a secondary procedure for keel removal. We introduce a novel, 1-stage endoscopic laser anterior commissurotomy for preventing anterior glottic web re-formation. Twenty patients with glottic webs involving the anterior commissure were studied. The lesions were removed by transoral carbon dioxide laser microsurgery. In all patients, the anterior glottic web was vaporized along with the inner perichondrium of the thyroid cartilage over the anterior commissure area, creating a raw vertical break "alley" between the anterior vocal folds that measured between 0.3 and 0.5 cm in width and between 0.8 and 2 cm in length. The preoperative and postoperative vocal folds and voice quality were evaluated by videostrobolaryngoscopy and voice recordings. All 20 patients had anterior glottic webs ranging from 11% to 64% of the length from the anterior commissure to the vocal process. None of the patients developed restenosis at the anterior commissure of a severity similar to that of the initial lesion during follow-up (mean, 13 months; range, 3 to 44 months).All patients except 1 reported satisfaction with their voice improvement. Outcome analysis revealed that partial re-formation of the web was noted in 4 patients. One-stage, endoscopic laser anterior commissurotomy was effective and relatively safe for removing glottic webs, for preventing anterior glottic web re-formation, and for improving vocal fold performance among our patients.

Sternum-hyoid muscle transposition and arytenoid adduction for unilateral vocal cord paralysis

To explore the therapeutic effect of sternum-hyoid muscle transposition and arytenoid adduction for unilateral vocal cord paralysis (UVCP). Included in this study were 19 patients with UVCP lasted for 12 months to 15 years. The surgical technique was as follows. The thyroid cartilage was engaged with a skin hook and gently rotated anteriorly. The lateral-inferior corner of the thyroid cartilage was exposed and the muscular process of the arytenoid was identified. Then, the thyroid lamina on the involved side was parasagittally separated 5 mm off the midline. The inner perichondrium was carefully freed from the overlying thyroid cartilage. The lamina was retracted laterally, and a 3-0 prolene suture was placed through the muscular process and tied to the cricoid cartilage at the origin of the lateral cricoarytenoid muscle. A bipedicled strap muscle flap was then transposed into the space between the lamina and the inner perichondrium. Pre- and postoperative voice evaluations measured mean fundamental frequency, jitter, shimmer, harmonic ratio and maximal phonation time, as well as assessments of voice quality. Vocal improvement was obtained in 100% (19 of 19) of patients. Immediately after the operation, the ingression could be observed in vocal cord membrane and vocal process, vocal cord volume was amplified. There was a significant difference (P < 0.05) in all parameters (fundamental frequency, jitter, shimmer, harmonic ratio and maximal phonation time) between pre- and postoperative voice evaluations measured mean. There was no significant difference (P > 0.05) in voice evaluations measured mean between 2 months and 12 months after operation in all patients. No major complications were noted in any patient. Sternum-hyoid muscle transposition and arytenoid adduction for unilateral vocal cord paralysis is simple and convenient, no immune rejection, and the long-term result is stable.

Comparison of intravenous general anaesthesia vs endotracheal intubation in the surgical management of juvenile onset recurrent respiratory papillomatosis

Conclusions: Both intravenous general anaesthesia (IVGA) and general anaesthesia with endotracheal intubation (GA with ET) are applicable for the procedure of juvenile onset recurrent respiratory papillomatosis (JO-RRP). GA with ET was found to be better for JO-RRP patients with dyspnoea, as it provided better stabilization of the vital signs with fewer postoperative complications. Objectives: To evaluate the safety and efficacy of two different anaesthetic techniques in the removal of JO-RRP. Methods: A total of 52 JO-RRP patients with mild dyspnoea were included in the study. Each case underwent two procedures, one by IVGA and the other by GA with ET. A total of 104 procedures were performed. The effectiveness and safety of the two anaesthetic techniques were pairwise compared. Results: There were no significant differences in anaesthetic recovery time, operative time or postoperative voice quality between the two anaesthetic groups. However, significant differences in heart rate, oxygen saturation and carbon dioxide saturation were observed. Some patients who underwent IVGA developed apnoea (28.8%) and laryngeal spasm (19.2%). These complications were not observed in the GA with ET group.

Transoral Laser Microsurgery for Malignancies of the Upper Aerodigestive Tract

AbstractTransoral laser microsurgery (TLM) is an important option in the treatment plan for tumors of the oral cavity, oropharynx, larynx, and hypopharynx. For properly selected patients, TLM provides equivalent oncologic outcomes when compared to traditional therapies, while improving the functional aspects of postoperative speech, voice and swallowing.

Voice production mechanisms following phonosurgical treatment of early glottic cancer.

Although near-normal conversational voices can be achieved with the phonosurgical management of early glottic cancer, there are still acoustic and aerodynamic deficits in vocal function that must be better understood to help further optimize phonosurgical interventions. Stroboscopic assessment is inadequate for this purpose. A newly developed color high-speed videoendoscopy (HSV) system that included time-synchronized recordings of the acoustic signal was used to perform a detailed examination of voice production mechanisms in 14 subjects. Digital image processing techniques were used to quantify glottal phonatory function and to delineate relationships between vocal fold vibratory properties and acoustic perturbation measures. The results for multiple measurements of vibratory asymmetry showed that 31% to 62% of subjects displayed higher-than-normal average values, whereas the mean values for glottal closure duration (open quotient) and periodicity of vibration fell within normal limits. The average HSV-based measures did not correlate significantly with the acoustic perturbation measures, but moderate correlations were exhibited between the acoustic measures and the SDs of the HSV-based parameters. The use of simultaneous, time-synchronized HSV and acoustic recordings can provide new insights into postoperative voice production mechanisms that cannot be obtained with stroboscopic assessment.

Transoral laser ventricular fold resection and thyroarytenoid myoneurectomy for adductor spasmodic dysphonia: Long‐term outcome

A transoral approach to laser myoneurectomy of the thyroarytenoid muscles was recently reported as an effective technique for treatment of adductor spasmodic dysphonia (ASD). The short-term results were encouraging. In this study, a long-term surgical outcome of this technique is investigated. A prospective clinical series. Fifty-two patients with ASD underwent transoral laryngomicrosurgery with a CO(2) laser to resect the ventricular folds followed by myoneurectomy of the thyroarytenoid muscles. The nerve fibers of recurrent laryngeal nerve terminating at the thyroarytenoid muscle, which were frequently found branching deeply among the posterior belly of this muscle, were vaporized. Care was taken not to damage the vocal ligaments, lateral cricoarytenoid muscles, or arytenoid cartilages. Pre- and postoperative subjective voice assessments, and acoustic and aerodynamic measurements, were performed and statistically analyzed. Twenty-nine of the 52 patients who were followed up for more than 12 months (range, 12-63 months; mean, 31 months) were studied. Moderate and marked vocal improvement was achieved in 90% (26/29) of the patients. Three patients had 30% improvement, which was reported as unsuccessful. Eight of the 26 patients who were satisfied with their postoperative voice still had a mild strain during phonation. Of the eight patients, seven achieved normal or nearly normal voice quality after revision laser surgery. No significant vocal deficit or paralysis was observed in any patient. After long-term follow-up of 31 months on average, approximately 90% of the ASD patients obtained moderate to marked improvement of vocal performance after transoral laser surgery. The long-lasting outcome is encouraging.

Long-term voice outcome following partial cricotracheal resection in children for severe subglottic stenosis

Objective To correlate the postoperative voice outcome to preoperative glottic involvement, following partial cricotracheal resection (PCTR) in children. The glottic involvement was analysed based on the extent of subglottic stenosis (SGS) in the endoscopic image and functional dynamic assessment using flexible endoscopy. Methods We conducted an interobserver study in which two ENT surgeons, blinded to one another's interpretation, independently rated the extent of SGS based on the endoscopic image along with the dynamic functional airway assessment, of 108 children who underwent PCTR for grade III or IV stenosis. Based on the observation, the glottic involvement was rated into 4 categories: A. SGS clear from vocal cords (3–4 mm below vocal cords). B. SGS reaching the free border of vocal cord and/or the posterior commissure with slightly limited abduction with no true posterior glottic stenosis (PGS). C. SGS with associated PGS or vocal cord fusion without cricoarytenoid ankylosis (CAA). D. Transglottic stenosis with/or without bilateral CAA. Evaluation of the voice was based on a parent/patient proxy questionnaire sent in 2008 to assess the current functional status of the patient's voice. Results Among the 77 patients available for long-term outcome with a minimum 1-year follow-up, 31 patients had isolated SGS free from vocal cords (group A) and 30 had SGS reaching the under surface of vocal cords with partial or no impairment of abduction of vocal cords (group B). Twelve patients belonged to group C with posterior glottic stenosis and/or vocal cord fusion (without cricoarytenoid ankylosis) and 4 patients had transglottic stenosis and or/bilateral cricoarytenoid ankylosis (group D). The long-term voice outcome following PCTR as perceived by the parent or patient was normal in 18% (14 of 77 patients) and the remaining 63 patients demonstrated mild to severe dysphonia. Patients belonging to group A and B exhibited either normal voice or mild dysphonia. Patients in group C demonstrated dysphonia, which was moderate in severity in the majority (83%). All patients in group D with transglottic stenosis and/or CAA showed severe dysphonia. Conclusion Children with associated glottic involvement are at high risk for poor voice outcome following PCTR. The severity of dysphonia was found to be proportional to the preoperative glottic involvement. Preoperative rating of the extent of glottic involvement based on endoscopic image and dynamic assessment was found to be useful in prognosticating the voice outcome.

Team Management of Voice Disorders in Singers

Team Management of Voice Disorders in Singers

Voice outcomes following repeated surgical resection of laryngeal papillomata in children

Objectives 1) To apply perceptual and acoustic voice assessments to children treated for juvenile-onset recurrent respiratory papillomatosis (JORRP); 2) to compare voice outcomes following treatment for JORRP using microdebrider versus carbon dioxide (CO 2) laser. Study Design Prospective cohort study. Setting This study was conducted at a tertiary pediatric academic center (March 2008-March 2009). Subjects and Methods Children with active JORRP were assessed using perceptual and acoustic voice analysis following treatment with either CO 2 laser or microdebrider. Outcome measures included overall severity rating, jitter, shimmer, and noise-to-harmonic ratio (NHR). The unpaired Student t test and Pearson correlation tests were used to explore the statistical significance of hypothesis tests. Results Eleven patients (8 male, 3 female) aged three to 17 years were enrolled. There were six children in the CO 2 laser cohort and five children in the microdebrider cohort. The immediate postoperative scores were significantly lower in the microdebrider cohort (vs the CO 2 cohort) for jitter, shimmer, NHR, and perceptual scores ( P < 0.05), indicating a better voice quality in the microdebrider group. Jitter, shimmer, and NHR showed a significant positive correlation with the proportion of CO 2 laser procedures ( P < 0.05). Conclusion This is the first study to use perceptual and objective acoustic evaluations to compare voice outcomes following microdebrider or CO 2 laser treatment of JORRP. The results of this study suggest that treatment with the microdebrider results in a better immediate and early postoperative voice outcome. Moreover, the data demonstrate a correlation of worsening voice quality with increased exposure to the CO 2 laser.

Vocal fold paralysis: role of bilateral transverse cordotomy

Although modern endoscopic laser techniques aim to avoid a permanent tracheostomy by augmenting the glottic aperture in cases of bilateral vocal fold palsy, loss of tissue from the posterior glottis risks compromising voice quality and swallowing function. The objective of this study was to describe our experience with bilateral transverse posterior cordotomy. This was a retrospective analysis of functional outcomes in a series of consecutive patients undergoing a simple modification of the classical laser cordectomy procedure, which avoids tissue loss. The procedure was confined to the complete release of the vocal ligament from the arytenoid cartilage on both sides, while avoiding any significant loss of mucosa or cartilage. Post-operative voice quality and quality of life were rated as good by most patients, which makes bilateral transverse cordotomy an attractive treatment option for bilateral vocal fold paralysis. Bilateral transverse cordotomy is a reliable treatment option for patients with bilateral vocal fold paralysis, and aims to avoid the morbidity associated with a permanent tracheostomy.

Therapeutisches Vorgehen bei dislozierten Larynxfrakturen

Acute trauma with laryngeal fracture is a rare injury affecting all functions of the larynx. Resuscitation follows the ABC principles for acute trauma life support. The priority has always been the establishment of an adequate and secure airway. To achieve optimal therapeutic long-term results, permanent stabilisation of the airway and good functional restoration of phonation and swallowing are necessary. We describe the therapy and long-term follow-up of two patients who suffered laryngeal fracture. The first case concerns a 31-year-old woman who suffered polytrauma with laryngotracheal separation in a car accident. The fracture was reduced and fixed utilizing miniplates. After decannulation the patient had a patent airway. She regained normal voice and was able to swallow without difficulty. The other case concerns a 16-year-old boy who suffered a laryngeal fracture in a bicycle accident. He also underwent subsequent operative therapy using adaptation plates. This patient also regained an adequate airway and a good postoperative voice. There were no problems with swallowing. Chondrosynthesis with adaptation plates provides an enduring and exact fixation of laryngeal fractures. In the long term, this leads to a stable recovery of function concerning airway, voice, and swallowing.

Marsupialization of Vocal Fold Retention Cysts: Voice Assessment and Surgical Outcomes

Although total excision remains the standard treatment for vocal fold retention cysts, postoperative deficits and damage to the vocal folds still occur. Marsupialization is a more conservative technique and can prevent these complications. In this prospective clinical series, 25 patients underwent the marsupialization procedure. Under a direct laryngomicroscope, the cystic wall margin was retracted medially with microforceps. An incision was made with microscissors encircling the equator of the cyst. The cyst contents drained from the cystic cavity when the capsule was sectioned. For 7 patients with concomitant marked vocal fold atrophy, strap muscle transposition laryngoplasty was simultaneously performed. All patients had complete preoperative and postoperative voice parameter analyses. A subjective improvement in voice quality was reported by 23 of the 25 patients (92%). A small recurrent vocal fold cyst was detected in 1 patient. Small vocal fold deficits and sulcus vocalis were detected in 2 and 4 patients, respectively. Only 1 patient described a worse voice after operation. No other complications were noted. Marsupialization of vocal fold retention cysts is a simple, relatively safe, and effective surgical treatment. Voice improvement, a low incidence of recurrence, and minimal vocal fold deficits demonstrate the validity of this technique. Marked preoperative vocal fold atrophy or postoperative glottal gap can be managed with medialization laryngoplasty.