Unilateral Vocal Fold Paresis Research Articles

Outcomes of a first point of contact speech language therapy clinic for patients requiring vocal cord check pre and post thyroid/parathyroid surgery.

Speech Language Therapy First Point of Contact Clinic (SLT-FPOCC) models can assist assessment of low-risk patient populations referred to ear, nose and throat (ENT) services. To further improve ENT waitlist management and compliance with best-practice care, consideration of other low-risk populations that could be safely managed through this service model is needed. The aims of this paper are to evaluate the clinical and service outcomes of completing vocal cord check (VCC) assessments for patients' pre and post thyroid/parathyroid surgery within an SLT-FPOCC model and examine consumer perceptions. The service followed existing SLT-FPOCC procedures, with ENT triaging referrals, then SLT completing pre- and postoperative VCC assessment (interview, perceptual assessment, flexible nasendoscopy), with assessment data later reviewed by ENT to diagnose laryngeal pathology. Clinical and service outcomes were collected prospectively. Patients completed an anonymous post-service satisfaction survey. Of the first 100 patients referred for preoperative VCCs, SLT assessment identified 42 with dysphonia and 30 reporting dysphagia, while ENT confirmed 9 with significant preoperative anatomical findings. Eighty-three underwent surgery, with 63 (95 nerves at surgical risk) returning for a postoperative VCC. Postoperative VCC identified three temporary neuropraxias (3.2%) and three unilateral vocal fold paresis (3.2%). Patients were highly satisfied with the service. All 163 pre-/postoperative VCCs were completed with no adverse events. The current data support SLT-FPOCC service expansion to include pre and post thyroid/parathyroid surgery VCC checks, with positive consumer perception. The model supports delivery of best practice management (i.e., pre- and postoperative VCC) for patients receiving surgery for thyroid/parathyroid dysfunction, and associated efficiencies for ENT services. What is already known Assessment of laryngeal function via flexible nasoendoscopy is recommended best practice for patients pre and postthyroid/parathyroid surgery, as recurrent laryngeal nerve injury is a low incidence (<10%), yet well-recognised risk of these surgeries. Traditionally, general surgeons refer presurgical patients to ear, nose and throat (ENT) for vocal cord check (VCC) assessment. However, with access to specialist outpatient services under increasing pressure, there is growing support for utilisation of other health professionals, such as speech-language therapists working in first point of contact (FPOCC) models, to assist with the administration of pre- and postsurgical assessments of such low-risk populations. What this study adds This work expands on the emerging body of evidence for speech language therapy (SLT) led FPOCC models within ENT outpatient services, providing clinical and service outcomes to support the safety of a new model designed to administer VCCs for patients pre and post thyroid/parathyroid surgery. Adopting a similar model to a prior published SLT-led FPOCC model, the trained SLT completes the pre- and postsurgical VCC including flexible nasoendoscopy and videostroboscopy, with images and clinical information then presented to ENT for diagnosis and management planning. This study also provides the first data on consumer perceptions of this type of service model. Clinical implications of this study Data on 100 consecutive presurgical patients revealed positive service findings, supporting the safety of this model. Nature and incidence of clinical findings pre and post surgery were consistent with previously published studies using traditional models of care (i.e., ENT completing the flexible nasendoscopy). Consumer perception was positive. This model enables delivery of pre-and postsurgical assessments for patients receiving thyroid/parathyroid surgery, consistent with best practice care, and reduces burden on ENT services. In total 163 ENT appointments were avoided with this model, with positive implications for ENT waitlist management.

Some aspects of surgical strategies in patients with thyroid cancer with metastatic lesions of the neck lymph nodes

Objective — to improve the surgical treatment of patients with thyroid cancer with metastatic lesions of the neck lymph nodes by means of an individual approach to diagnostics, intraoperative imaging, and choice of optimal surgical technique.&#x0D; Materials and methods. The analysis involved results of examinations and treatment of 749 patients. The following was taken into account: complaints, thyroid and lymph nodes ultrasound, thyroid hormones level, results of general clinical examinations. Levels of parathyroid hormone, vitamin D, magnesium, total and ionic calcium were determined at the preoperative stage. In some cases, computer tomography results were included. A fine‑needle aspiration (FNA) biopsy was performed to all patients. Women prevailed: 607 from 749 (81.0%; 95% CI 78.0—83.8). The mean age of the patients was 51.3% (45.6—59.1) years. The causes of disease included: colloid nodular goiter 566 (75.6%; 95% CI 72.3—78.6), nodular (adenomatous) goiter with follicular neoplasm 72 (9.6%; 95% CI 7.6—12.0), papillary carcinoma 54 (7.2%; 95% CI 5.5—9.3), suspicious for papillary thyroid carcinoma (according to the cytology results) 17 (2.3%; 95% CI 1.3—3.6), medullary carcinoma 12 (1.6%; 95% CI 0.8—2.8), anaplastic thyroid cancer 6 (0.8%; 95% CI 0.3—1.7), other tumors 22 (2.9%; 95% CI 1.8—4.4). Statistical processing of the obtained results was carried out by using the standard program package «Statistica 6.0 for Windows» (StatSoft, USA).&#x0D; Results. Surgical interventions were performed in 89 of 749 (11.9%; 95% CI 9.7—14.4) patients with malignant tumors of the thyroid gland. The variety of surgical procedures performed on the thyroid gland: thyroidectomy performed in 81 of 89 patients (91%; 95% CI 83.1—96.0), hemithyroidectomy in 8 of 89 patients (9.0%; 95% CI 4.0—16.9). The reasons for the hemithyroidectomy: in 2 of 89 patients (2.2%; 95% CI 0.3—7.9) the diagnosis was not confirmed by express histological examination with suspicion for papillary thyroid carcinoma. In 6 other cases, single micro adenocarcinomas that ranged in size from 0.4 to 0.8 mm were found, without invasion into the tumor capsule, which was confirmed during a planned pathological examination. Lymphodisection of the central tissue, as an addition to thyroidectomy, was performed by us in 76 of 89 cases (85.4%; 95% CI 76.3—92.0). Metastatic lesions of the central tissue during pathological examination were found in 29 (32.6%; 95% CI 23.0—43.3) patients with papillary carcinoma, in 5 with medullary cancer (5.6%; 95% CI 1.8—12.6), in 6 cases with anaplastic thyroid cancer (6.7%; 95% CI 2.5—14.1). In 11 patients (12.4%; 95% CI 6.3—21.0) due to the metastatic spread to the platysma of the lateral triangle of the neck, its excision was performed. In 9 (10%; 95% CI 4.7—18.3) patients were performed thyroidectomy with sheath‑fascial excision (removal) of the neck tissue. The precession method was used to visualize the upper laryngeal nerve in order to prevent traumatization. The upper parathyroid glands served as the first anatomical landmark of the recurrent nerve, which were identified in 72 (80.9%; 95% CI 71.2—88.5) patients. Temporary unilateral vocal fold paresis was observed in 3 (3.4%; 95% CI 0.7—9.5) patients. Wound drainage was carried out separately by leaving micro‑drainage, for active aspiration, which was evacuated in 2 days.&#x0D; Соnclusions. One of the main prerequisites for the high‑quality performance surgery of thyroid gland is the precise nature of surgical manipulations with careful observance of tactical and technical requirements for a surgeon: timely identify and precisely mobilize. The choice of the final surgical intervention on lymphatic collectors in thyroid cancer is directly dependent on the preoperative and intraoperative pathological examination. However, given the substantial proportion of metastatic lesions of the central zone lymph nodes (level VI), the technical complexity of repeated operative interventions in this area, it is recommended to perform a preventive removal of the central fiber.

Does the Severity of Vocal Fold Paresis on Laryngeal Electromyography Correlate With Radiographic Findings on Cross Sectional Imaging?

Unilateral vocal fold paresis or paralysis (UVFP) is a condition for which radiographic evaluation and laryngeal electromyography (LEMG) are valuable to evaluate severity of injury and direct treatment plans. Despite extensive research involving findings suggestive of UVFP with radiographic imaging, no study has attempted to determine which findings suggestive of UVFP on imaging are clinically significant and suggest a need for intervention. The purpose of this study was to evaluate whether the severity of vocal fold paresis/paralysis affects the likelihood of encountering radiographic findings suggestive of UVFP. We also aimed to determine which findings suggestive of UVFP on imaging were clinically significant and were associated with surgical intervention. A retrospective chart review was conducted of patients who had been diagnosed with unilateral vocal fold paresis or paralysis and had been evaluated by CT scan and/or magnetic resonance imaging and laryngeal electromyography (EMG) between the dates of January 1, 2017 and January 9, 2018. Fisher's exact testing with Monte Carlo Simulation was utilized to determine statistical significance of identified relationships.Univariate analysis was conducted to assess for individual relationships between imaging results and the potential predictor variables. Chi square analysis was conducted with the various categorical variables to assess for any potential relationships to imaging results. Statistical significance was determined utilizing chi square analysis. After data collection, 130 patients were included in the study population. Of the 112 patients with documented MRI results, 17% had a reported imaging abnormality suggestive of true vocal fold paresis or paralysis (VFP). Of the 71 patients with documented CT Neck results, 15.4% had an abnormality potentially concerning for true VFP. The average decrease in recruitment of the right and left SLN was 23.8% and 26.1%, respectively. The average decrease in recruitment of the right and left RLN was 37.3% and 57.78%, respectively. Seventy four percent of patients who exhibited abnormal MRI were found to have isolated SLN weakness, and 21% of patients were found to have a combined SLN and ipsilateral RLN weakness. In patients with abnormal CT scans 45% were found to have isolated SLN weakness, and 35% were found to have a combined SLN and RLN weakness. MRI imaging again failed to display any significant degree of paresis. However, abnormal CT results displayed severe CN X paresis in 36.84% vs 1.96% in normal scans. The chance of an abnormal MRI and CT result was 2.78 and 5.55 times greater, respectively, for each increase in the degree of severity of CN X paresis. When looking at the ability of imaging to predict the chance of a patient undergoing surgery, 34.8% of patients with an abnormal MRI underwent surgery compared to just 14.61% of those with normal scans. For CT scans, 35% of patients with an abnormal scan underwent surgery, compared with only 15.69% with normal imaging. When pooled, over 33% of patients with any abnormal imaging underwent a laryngeal procedure compared to 13% of patients with normal imaging. There is a relationship between severity of vocal fold paresis found on laryngeal EMG and likelihood of detection on imaging. While CT was more likely to find characteristics of UVFP than MRI, patients who had an abnormal finding on either modality were more likely to undergo surgical intervention. These findings highlight the importance of early referral of patients with abnormal laryngeal imaging to an otolaryngologist for evaluation and possible intervention.

Односторонний парез гортани: особенности клинической картины и сложности диагностики

The article presents the experience of the phoniatric department of the Saint Petersburg Institute of Ear, Throat, Nose, and Speech in the management of patients with unilateral vocal fold paresis. Variants of the clinical picture of the disease that complicate the compensation of the phonatory, respiratory, and protective functions of the larynx have been studied. The most common clinical picture of unilateral laryngeal paresis is the presence of complaints of hoarseness, diplophonia, inspiratory dyspnea during physical activity, aspiration. However, complaints about the voice may be absent, or they may be presented in the form of an aphonia. Patients may not complain of shortness of breath, or inspiratory stridor appears with minimal physical activity, snoring with episodes of apnea, laryngospasm attacks. The article presents cases of rare manifestations of paresis associated with the phenomena of hypotension and hypotrophy of the laryngeal muscles. These include the weakening of the tension of the medial edge of the vocal fold, thinning of the vocal fold, contouring of the vocal process of the arytenoid cartilage, lower location of the paralyzed vocal fold relative to healthy, rotation of the arytenoid cartilage, rotation of the epiglottis, and others. Compensatory mechanisms of phonation are described. Possible difficulties in diagnosing laryngeal paresis based on video laryngoscopy data, including hypomobility of the vocal fold, as well as options for simulating paresis due to neoplasms and post-traumatic changes in the larynx are considered.

Changes in Cough Airflow and Acoustics After Injection Laryngoplasty.

We explored the following hypotheses in a cohort of patients undergoing injection laryngoplasty: (1) glottic insufficiency affects voluntary cough airflow dynamics and restoring glottic competence may improve parameters of cough strength, (2) cough strength can be inferred from cough acoustic signal, and (3) glottic competence changes cough sounds and correlates with spectrogram morphology. Prospective interventional study. Subjects with glottic insufficiency secondary to unilateral vocal fold paresis, paralysis, or atrophy, and scheduled for injection laryngoplasty completed an instrumental assessment of voluntary cough airflow using a pneumotachometer and a protocolized voluntary cough sound recording. A Wilcoxon signed-rank test was used to compare the differences between pre- and post-injection laryngoplasty in airflow and acoustic measures. A Spearman rank-order correlation was used to evaluate the association between airflow and acoustic cough measures. Twenty-five patients (13F:12M, mean age 68.8) completed voluntary cough airflow measurements and 22 completed cough sound recordings. Following injection laryngoplasty, patients had a statistically significant decreased peak expiratory flow rise time (PEFRT) (mean change: -0.03 s, SD: 0.06, p=0.04) and increased cough volume acceleration (mean change: 13.1 L/s2 , SD: 33.9, p=0.03), suggesting improved cough effectiveness. Correlation of cough acoustic measures with airflow measures showed a weak relationship between PEFRT and acoustic energy (coefficient: -0.31, p=0.04) and peak power density (coefficient: -0.35, p=0.02). Our study thus indicates that injection laryngoplasty may help avert aspiration in patients with glottic insufficiency by improving cough effectiveness and that improved cough airflow measures may be tracked with cough sounds. 3 Laryngoscope, 133:S1-S14, 2023.

Влияние пандемии COVID-19 на заболеваемость гортани

Among the symptoms of COVID-19, scientists pay the most attention to damage to the lower respiratory tract, neurological and cardiovascular systems, gastrointestinal tract, psychoemotional disorders and anosmia. Less common are articles about the state of auditory and vestibular as well as voice disorders. Inflammatory changes of the larynx, trauma due to intubation and severe coughing, neuropathy of the recurrent laryngeal nerve, consequences of the pathology of the bronchopulmonary system, psychogenic factors are indicated as the cause of dysphonia. The purpose of our study is to determine the structure of laryngeal morbidity in voice professionals during the COVID-19 pandemic. The analysis of case histories of 2,438 patients of voice professions who applied to the phoniatric department of the Saint Petersburg Institute of Ear, Throat, Nose, and Speech was performed. The diagnosis, a history of COVID-19, dysphonia directly during COVID-19 were considered. The number of patients compared to the period before the COVID-19 decreased by 39,8% due to anti-epidemic measures. The leading causes were functional dysphonia (29,3%), acute and chronic laryngitis (27,8%). Tumor-like disease are in third place (19,1%). Paresis of the larynx (8,5%) was diagnosed less frequently compared to the period before the pandemic, which is associated with a reduction in the number of elective operations on the organs of the head and neck. The frequency of laryngeal neoplasms (4,1%) has remained at the same level, almost half of them are malignant. Congenital malformations of the larynx were found in 2,9% of patients. Vascular pathology of the vocal folds was detected in 1.1%, scar stenosis, in 0,5%, rare diseases of the larynx, in 0,6% of patients. Appeals on the other occasions accounted for 6,1% of cases. 43,7% of patient have had COVID-19. The direct connection of dysphonia with COVID-19 was revealed in 18,0% of them. The most common cause of impaired vocal function against the background of coronavirus infection were functional dysphonia (39,1%) and inflammatory diseases of the larynx (34,9%). Tumor-like disease became the next most common (17,2%). Vascular pathology of the vocal folds was found less frequently (5,2%). Unilateral vocal fold paresis was detected in 3,1% of patients. One patient suffered from chondroperichondritis with granuloma formation in the area of the arytenoid cartilage of the larynx (0,5%). In relation to the total number of examined patients, COVID-19 as the cause of dysphonia was 7,9% of cases.

Acute Vocal Fold Paresis and Paralysis After COVID-19 Infection: A Case Series.

Evidence demonstrates neurotropism is a common feature of coronaviruses. In our laryngology clinics we have noted an increase in cases of "idiopathic" vocal fold paralysis and paresis in patients with no history of intubation who are recovering from the novel SARS-Cov-2 coronavirus (COVID-19). This finding is concerning for a post-viral vagal neuropathy (PVVN) as a result of infection with COVID-19. Our objective is to raise the possibility that vocal fold paresis may be an additional neuropathic sequela of infection with COVID-19. Retrospective review of patients who tested positive for COVID-19, had no history of intubation as a result of their infection, and subsequently presented with vocal fold paresis between May 2020 and January 2021. Charts were reviewed for demographic information, confirmation of COVID-19 infection, presenting symptoms, laryngoscopy and stroboscopy exam findings, and laryngeal electromyography (LEMG) results. Sixteen patients presented with new-onset dysphonia during and after recovering from a COVID-19 infection and were found to have unilateral or bilateral vocal fold paresis or paralysis. LEMG was performed in 25% of patients and confirmed the diagnosis of neuropathy in these cases. We believe that COVID-19 can cause a PVVN resulting in abnormal vocal fold mobility. This diagnosis should be included in the constellation of morbidities that can result from COVID-19 as the otolaryngologist can identify this entity through careful history and examination.

Effects of Voice Therapy for Dysphonia due to Tension Imbalance in Unilateral Vocal Fold Paralysis and Paresis

Medialization procedures, such as type I thyroplasty, arytenoid adduction, and vocal fold injection, are popular treatments for dysphonia due to unilateral vocal fold paralysis (UVFP). However, dysphonia occasionally persists after medialization procedures owing to tension imbalance. This tension imbalance causes diplophonia, asymmetry and aperiodic vibrational flutter in travelling wave motion. Currently, there is no established treatment for tension imbalance. We herein report two cases with residual dysphonia due to tension imbalance following medialization for chronic UVFP, and another case presenting with dysphonia due to tension imbalance following chronic unilateral vocal fold paresis. Three patients underwent voice therapy using flow phonation to facilitate increased airflow management in speech as well as forward oral resonance by focusing on balanced airflow. Phonatory outcomes were evaluated using stroboscopic findings, aerodynamic and acoustic measures, as well as self-rating. Aerodynamic assessments, acoustic findings and self-ratings improved in all three cases after voice therapy. Stroboscopic findings prior to voice therapy showed asymmetric vibration with glottic gap, which was improved after voice therapy. Fundamental frequency (F0) also increased post-therapy. In a previous canine study, it was shown that enhanced breath support with expiratory airflow resulted in increased F0, suggesting that enhanced breath support could increase vocal fold tension. The increased F0 achieved in the present cases following voice therapy may increase vocal fold tension with breath support. Thus, voice therapy using flow phonation may be effective for supporting vocal fold tension and improving dysphonia due to tension imbalance following UVFP and paresis.

A 4-year Retrospective Review of the Presence and Pattern of Ventricular Hyperadduction Following Unilateral Vocal Fold Paralysis, Paresis, and Unilateral Cordectomy

The aim of our study was to determine the presence and pattern of ventricular hyperadduction (VH) following unilateral vocal fold (VF) paralysis/paresis and that following unilateral cordectomy (UC). The authors independently reviewed charts and flexible videostroboscopic recordings of 214 patients diagnosed with unilateral VF paralysis/paresis and those who had undergone UC from 2015 to 2018. The presence and pattern of VH was noted. VH was considered to be present when the false vocal fold (FVF) obliterated 50% or more of the true vocal fold width during phonation, with or without FVF vibration. The true vocal fold width was considered to be that which was visible on abduction of the VFs. Categorical variables were presented in numbers and percentages and qualitative variables were correlated using Chi-Square test. Odds ratio with 95% Confidence Interval was calculated. In 154 patients diagnosed as unilateral VF paralysis/paresis 85 patients had a VH pattern (55.19%) with contralateral VH observed in 74 (87.05%), ipsilateral VH observed in 6 (7.05%) and bilateral VH observed in five patients (5.88 %). The total number of patients of UC was 60 with 36 of these patients developing a VH (60%). Ipsilateral VH was observed in 28 of these 36 patients (77.77%), three patients developed contralateral VH (8.33%) and five patients developed bilateral VH (13.88%). Ipsilateral ventricular hyper-adduction following unilateral cordectomy in the group of patients that develop hyperadduction is a significant finding in our study suggesting possibility of unilateral central phonatory control of the FVF. Contralateral ventricular hyper-adduction following unilateral paralysis and paresis, in the group of patients that develop hyperadduction is a significant finding in our study and this finding resonates with previously published papers. A finding of unilateral VH may serve as a possible indicator of the occasionally challenging diagnosis of vocal fold paresis. Retrospective, Observational.

Laryngeal Burn from a Sweet Potato: A Case Report

CONTEXTThermal injury to the larynx and other pharyngeal structures as a result of food ingestion is a rare occurrence, particularly in an adult population. Since the 1970’s, only a few cases have been reported in the literature.CASE PRESENTATIONWe present the case of a male in their early 30’s with a history of left sided spastic hemiparesis and unilateral vocal fold paresis who ingested a sweet potato which resulted in supraglottic burns. The patient denied any prior swallowing difficulties. Conservative therapy with steroids, proton pump inhibitors (PPI’s) and antibiotics were sufficient for full recovery without any lasting sequelae.CONCLUSIONSThis case demonstrates how careful attention should be paid to food temperature particularly in patients at higher risk of dysphagia. It also demonstrates how prompt diagnosis and implementation of appropriate medications can prevent permanent and debilitating damage.

Update: Behavioral Management of Unilateral Vocal Fold Paralysis and Paresis

PurposeVocal fold motion impairment (VFMI) can be the result of iatrogenic or traumatic injury or may be idiopathic in nature. It can result in glottic incompetence leading to changes in vocal quality and ease. Associated voice complaints may include breathiness, roughness, diplophonia, reduced vocal intensity, feeling out of breath with talking, and vocal fatigue with voice use. A comprehensive interprofessional voice evaluation includes auditory-perceptual voice evaluation, laryngeal examination including videostroboscopy, acoustic and aerodynamic voice measures. These components provide valuable insight into laryngeal structure and function and individual voice use patterns and, in conjunction with stimulability testing, help identify candidacy for voice therapy and choice of therapeutic techniques.ConclusionA comprehensive, interprofessional evaluation of patients with VFMI is necessary to assess the role of voice therapy and develop a treatment plan. Although there is no efficacy data to support specific voice therapy techniques for treating VFMI, considerations for various techniques are provided.

Lewis-Sumner Syndrome Manifesting as Unilateral Vocal Fold Paresis and Laryngeal Fasciculations

Lewis-Sumner syndrome (LSS) is a rare disease characterized by asymmetrical and multifocal mononeuropathy commonly located in the upper limbs. Some rare cases affecting cranial nerve have been described, but LSS is unknown to affect especially laryngeal nerves. This paper presents the first case of unilateral vocal fold paresis caused by an LSS in a 59-year-old man complaining of dysphonia, breathy voice, and vocal fatigue. Epidemiology, clinical features, diagnosis, and treatment will be described.

Injection laryngoplasty as miniinvasive office-based surgery in patients with unilateral vocal fold paralysis - voice quality outcomes.

IntroductionInjection laryngoplasty (glottis augmentation) is the preferred method in surgical management of unilateral vocal fold paralysis (UVFP). Traditionally, these procedures are performed in the operating room. Nowadays, however, these procedures have moved into the office.AimTo evaluate the voice quality after transoral injection laryngoplasty under local anaesthesia in patients with unilateral vocal fold paralysis.Material and methodsFourteen subjects (5 women and 9 men) with unilateral vocal fold paresis (9 with right vocal fold paresis and 5 with left vocal fold paresis) were included in the study. The mean age of the group was 57.8 ±19.0 years (32–83 years). All of the injection laryngoplasties were performed transorally, under local anaesthesia. The injection material was calcium hydroxylapatite. Before and 1, 3 and 6 months after the procedure the following variables were evaluated: voice perception, videostroboscopy, acoustic analysis, aerodynamic evaluation, and the subjective rating of the voice quality by the patient.ResultsAfter injection laryngoplasty, complete glottal closure was achieved or there was a significant improvement in the glottal closure of each subject. We noted great improvement in the post-injection objective and subjective voice outcomes and patients reported improvement in the voice-related quality of life.ConclusionsThe transoral approach for injection laryngoplasty under local anaesthesia is an effective and safe way to treat incomplete glottal closure in patients with UVFP. The transoral approach is an efficient alternative to other surgical techniques used for vocal fold injection.

Medialization Laryngoplasty After Injection Augmentation

This study aims to assess the effect of vocal fold injection augmentation (IA) on subsequent medialization laryngoplasty (ML). A retrospective cohort study with follow-up telephone survey was carried out. Clinical records of patients with unilateral vocal fold paralysis or paresis (VFP) who underwent ML between April 2006 and March 2015 were reviewed. Patients who underwent IA before ML were compared with patients who did not, with respect to demographic information, symptoms, Voice Handicap Index-10 (VHI-10), etiology of VFP, and revision rate. Among patients undergoing IA, the effects of injection material and of interval from IA to ML on revision rate were assessed. Follow-up telephone surveys were conducted to evaluate long-term outcomes using VHI-10 and a condition-specific questionnaire. One hundred thirty-five patients (70 male:65 female) with vocal fold paralysis (125) or paresis (10) underwent ML (96 left:39 right). Sixty-six (48.9%) patients underwent concurrent arytenoid adduction. Fourteen (10.4%) patients required revision. Fifty-six (41.5%) patients had prior IA; five (8.9%) patients underwent revision. Seventy-nine (58.5%) patients did not have IA; nine (11.4%) patients required revision (P = 0.78). Neither augmentation material nor length of interval between last IA and ML affected the revision rate (P = 1.00; P ≥ 0.11 for all tested intervals, respectively). No difference in follow-up VHI-10 score was found between patients who had IA before ML and patients who had not (P = 0.73). IA does not appear to affect the revision rate or long-term outcome of subsequent ML.

Paediatric injection medialisation laryngoplasty: Recent Great Ormond Street Hospital experience

IntroductionUnilateral vocal fold paresis may significantly impair the vocal quality and laryngeal competence of a child. Relatively little literature relates to injection medialisation laryngoplasty (IML) in children and previous reports have involved small numbers of heterogenous cases. MethodsA retrospective review was conducted of paediatric patients managed by our multidisciplinary specialist voice clinic undergoing IML for unilateral vocal fold paresis. Cases of bilateral paresis, those characterised by vocal fold fixation, and patients without formal pre and post-operative voice evaluation were excluded. ResultsEighteen IML procedures were performed in 12 children eligible for inclusion between 2005 and 2015. The average age at time of procedure was 12 years (range 9–15 years). Autologous fat was used in 5 procedures, succeeded by calcium hydroxylapatite (Radiesse® Voice) from 2011 (n = 13). A significant improvement in median GRBAS score components was observed after calcium hydroxylapatite injection in terms of grade (p = 0.008), breathiness (p = 0.002) and aesthenia (p = 0.016). A pre- and post-procedural Voice Handicap Index was self-completed by 6 patients receiving calcium hydroxylapatite injection; the median change in score was an improvement of 19 points (interquartile range 36.5). ConclusionWe describe the outcomes of a comparatively large paediatric series and have found IML using calcium hydroxylapatite to be a reliable technique associated with improved subjective outcome measures. Management of UVCP in the child is a challenge with particular investigative and interventional considerations. Further study supported by high quality subjective and, where possible, objective outcome measures, is required to better inform patient selection, timing of intervention and choice of injection material.

Medialization thyroplasty in glottis insufficiency due to unilateral vocal fold paralysis and after laser cordectomies - preliminary report.

The evaluation of voice results in patients after medialisation throplasty. In Otolaryngology Department of Medical University of Warsaw there were performed so far 8 thyroplasty procedures under local anaesthesia with implantation of medical silicon protesis. 6 patients had unilat¬eral vocal fold paresis and the rest two underwent in the past laser cordectomy due to T1a vocal carcinoma. There were no complications during and post the surgery. The follow up examination in 1st , 3rd, 6th i 12th months postoperatively revealed for all patients significant improvement of glottal closure in laryngeal videostrobos¬copy. The voice quality improved both in perceptual evaluation (GRBAS scale) and acoustic analysis (F0, jitter, shim¬mer, NHR) in both patients groups. However the rate of improvement was much more significant in group with uni¬lateral vocal fold paresis. In all patients the maximum phonation time (MPT) increased. The self-evaluation of voice quality with Voice Handicap Index questionnaire confirmed also individual improvement. The speech rehabilitations is not successful in each patient with glottis insufficiency. The medialisation thyroplasty remains the standard procedure for permanent improvement of voice quality in those cases.

Repeat Imaging in Idiopathic Unilateral Vocal Fold Paralysis: Is It Necessary?

Imaging plays a critical role in the evaluation of patients presenting with unilateral vocal fold paresis or paralysis of unknown etiology. In those with idiopathic unilateral vocal fold paralysis (iUVFP), there is no consensus regarding the need or timing of repeat imaging. This study seeks to establish the rate of delayed detection of alternate etiologies for these patients to determine if and when imaging should be repeated. Retrospective chart review was conducted identifying patients at our institution with vocal fold movement impairment between 1998 and 2014. Idiopathic paralysis was diagnosed if physical examination, laryngoscopy, and initial imaging excluded a cause. Demographic data, length of follow-up, and the presence of late lesions were noted. Time to detection was plotted using the Kaplan-Meier method. Of 3210 patients reviewed, 207 had a diagnosis of iUVFP. Of these patients, 8 went on to develop alternate diagnoses, including pulmonary disease, skull-base and laryngeal neoplasms, and thyroid malignancy. In Kaplan-Meir analysis, 90% remained "idiopathic" at 5 years of follow-up. The mean time to detection was 27 months. Patients initially diagnosed with iUVFP may have an occult cause that later becomes evident. We recommend repeat imaging within 2 years after diagnosis, but this is likely unnecessary beyond 5 years.

Effect of vocal fold asymmetries on glottal flow.

Voice disorders, such as unilateral vocal fold paralysis or paresis, and vocal fold scarring feature structural asymmetries of the vocal folds. Studies on how structural asymmetries affect voice has mostly been limited to computational simulations and experiments on mechanical models. The purpose of the current study is to examine the effects of asymmetries in left-right position, height, and length of the vocal folds on the intraglottal flow characteristics, as well as acoustics in the canine larynx model. Basic science. Measurements of intraglottal flow velocity fields were taken in excised canine larynges using particle image velocimetry. Asymmetries of the vocal folds are induced by translating the vocal processes in space using a prong apparatus connected to a micrometer. Asymmetries in length height and abduction produced a reduction in the intraglottal vortices strength and subsequently the glottal efficiency. Current findings can affect future recommendations for surgical interventions that are used to treat unilateral vocal fold paralysis. NA Laryngoscope, 126:2534-2538, 2016.

On the problem of voice rehabilitation in the case of unilateral vocal fold paresis

Unilateral vocal fold paresis (UVFP) significantly deteriorates the patient's quality of life. The leading role in the rehabilitation of the patients presenting with UVFP belongs to stimulation therapy which consists in the activation of muscle re-innervation of the larynx and the compensatory mechanisms allowing to achieve the most complete closure of the vocal folds during phonation. The objective of the present study was the optimization of the conservative treatment of patients with UVFP. Fifty patients at the age varying from 18 to 70 years presenting with UVFP (the duration of the disease less than 6 months underwent the comprehensive treatment including electrostimulation of the larynx, vitamin therapy, and speech therapy. The patients were divided into two groups: A and B comprised of 25 subjects each. Those of Group A were given, in addition to the standard treatment, a 1.5 month-long course of Neuromidin therapy. The results of the treatment were evaluated with the use of laryngostroboscopy, flowmetry, the GRBAS scale, acoustic voice analysis (lingWaves), and the VHI questionnaire. The restoration of vocal fold mobility was achieved in 20% and 8% of the patients of groups A and B respectively. The clinical effect was absent in 12% of the patients in Group A and 28% of the patients in Group B. The differences between groups were statistically significant (p<0.05). In the remaining cases, the positive dynamics of the flowmetric characteristics, GRBAS and VHI data, maximum phonation time, Jitter, DSI, frequency and dynamic ranges as well as the intensity of voice were documented in 68% of patients in Group A and 64% of patients in Group B). The results of the study confirm the usefulness of the combined treatment of UVFP consisting of electrostimulation of the larynx together with speech therapy and application of cholinergic drugs. The addition of Neuromidin to the conventional scheme of conservative treatment can further improve its efficiency from 72% to 88%.

Analysis of laryngoscopic features in patients with unilateral vocal fold paresis.

The diagnosis of paresis in patients with vocal fold motion impairment remains a challenge. More than 27 clinical parameters have been cited that may signify paresis. We hypothesize that some features are more significant than others. Prospective case series. Two laryngologists rated laryngoscopy findings in 19 patients suspected of paresis. The diagnosis was confirmed with laryngeal electromyography. A standard set of 27 ratings was used for each examination that included movement, laryngeal configuration, and stroboscopy signs. A Fisher exact test was completed for each measure. A kappa coefficient was calculated for effectiveness in predicting the laterality of paresis. Left-sided vocal fold paresis (n = 13) was significantly associated with ipsilateral axis deviation, thinner vocal fold, bowing, reduced movement, reduced kinesis, and phase lag (P < .05). Right-sided vocal fold paresis (n = 6) was significantly associated with ipsilateral shorter vocal fold, axis deviation, reduced movement, and reduced kinesis (P < .05). Using these key parameters, the senior author was accurately able to diagnose the side of paresis in 89.5% of cases for a kappa coefficient of 0.78. Of the multiple features on laryngoscopy, glottic configuration, ipsilateral thin vocal fold, vocal fold bowing, reduced movement, reduced kinesis, and phase lag were more likely to be associated with vocal fold paresis. 4 Laryngoscope, 126:1831-1836, 2016.