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Objective: Evaluate long-term voice outcome after bilateral medialisation thyroplasty in glottic insufficiency due to vocal fold atrophy with or without sulcus. Methods: Patients after medialisation thyroplasty for vocal fold atrophy with or without sulcus were identified. Long-term post-operative subjective voice outcomes (> 1 year) using Voice Handicap Index-30, subjective ratings on voice aspects and study-specific questionnaire were compared to pre-operative and shorter-term (1 year) values. Results: Thirty-six patients were identified, of which 26 were included (16 atrophy, 10 sulcus) with median follow up of 6.7 years. Mean Voice Handicap Index score at > 1 year (40.0) showed clinically relevant (≥ 15 for groups) and statistically significant improvement compared to pre-operative score (58.1) and remained stable compared to post-operative score (35.7) at one year. Ten patients (56 per cent) reported clinically relevant improvement (≥ 10) after more than five years. Conclusion: Long-term improvement in subjective voice outcomes is attainable in a significant proportion of patients undergoing bilateral medialisation thyroplasty for atrophy with or without sulcus. [ABSTRACT FROM AUTHOR]

Objective: Conventional injection medialisation laryngoplasty techniques may be compromised by patient-specific factors such as marked kyphosis, an anteriorly positioned larynx or intolerance to nasendoscopy. This paper describes a technique for successful injection medialisation laryngoplasty where conventional methods are precluded, in an 88-year-old man with presbyphonia on a background of Parkinson's disease. Methods: After induction of general anaesthesia, a transoral introducing needle, shaped by tactile manipulation to match the curvature of a 'C-MAC' intubating video-laryngoscope 'D-blade' attachment, was introduced until visible above the glottis. The implant material was then injected into the paraglottic space as normal until satisfactory medialisation of the vocal fold was achieved. Results: When reviewed in the out-patient clinic four weeks later, the patient's post-operative Voice Handicap Index score fell to 6, from a pre-operative score of 21. Conclusion: By utilising commonly available equipment and anaesthetic support to recreate the views and access conventional nasendoscopy and laryngoscopy facilitate, this novel procedure provides a viable and proven alternative in uncommon but challenging cases. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to describe the epidemiology of laryngotracheal stenosis within a resource-constrained setting, whilst exploring the outcome correlates unique to Montgomery Safe-T-Tube stented laryngotracheoplasty. Methods: A retrospective cross-sectional study of patients who underwent Montgomery Safe-T-Tube stented laryngotracheoplasty between January 2000 and December 2019 was performed. Results: Amongst 75 patients, most lesions were iatrogenic (78.7 per cent) and high-grade in severity (84 per cent). Following 101 laryngotracheoplasties, 57 patients (76 per cent) were successfully decannulated. Young age (84.6 per cent; p = 0.009), low-grade stenosis (100 per cent; p = 0.034) and airway-framework structural integrity (79.3 per cent; p = 0.004) were significant correlates of success. Restenosis (n = 43; 57.3 per cent), occurring at a median of 9.37 weeks following decannulation, was predominantly associated with antecedent dilatation (96.3 per cent; p < 0.001). Conclusion: Demographic and clinical profiles play a pivotal role in the outcomes and complications of Montgomery Safe-T-Tube stented laryngotracheoplasty. The success rate validates the procedure within a resource-limited setting. There exist critical periods following both surgery and decannulation when the occurrence of adverse events is most likely. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the safety and biocompatibility of bone wax as an implant material for medialisation laryngoplasty in a large animal model. Methods: Three Dorper-cross ewes underwent type I thyroplasty of the right vocal fold with bone wax. The animals were monitored for four weeks for general wellbeing. The animals were euthanised and the larynges harvested. Histological evaluation was performed to assess for adverse tissue reaction and biocompatibility. Results: The mean (± standard deviation) amount of bone wax implanted was 0.49 g (± 0.12 g). No adverse events were reported. Ex vivo vibration was present on high-speed imaging for all medialised vocal folds. Histology demonstrated implanted paraffin embedded within the thyroarytenoid muscle with no evidence of resorption, a minimal inflammatory infiltrate, and a thin fibrotic capsule. Conclusion: The results of this investigation suggest that bone wax may be a safe and efficacious implant material for medialisation laryngoplasty. Further studies are necessary to assess its long-term safety and efficacy. [ABSTRACT FROM AUTHOR]

Objective: Laryngotracheal reconstructive surgery very often requires placement of laryngeal stents, but most of the available stents either do not conform to the shape of the glottis or are open at the upper end, causing significant tissue reaction and aspiration. LT-Mold is an ideal stent in this respect, but it is not readily available. Case report: The authors of this study fashioned a laryngeal stent out of a readily available Montgomery T-tube in such a way that it had a closed upper end and was well-conformed to the architecture of the larynx. This stent was used in a case of posterior expansion laryngoplasty, and post-operatively the patient had a patent airway with good voice and no aspiration. Conclusion: A customised laryngeal stent is well tolerated and helps to solve complicated cases of posterior glottic stenosis. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to establish arytenoid asymmetry as a pre-operative predictive parameter for arytenoid adduction surgery in unilateral vocal fold paralysis and thereafter identify the most predictive parameter for arytenoid adduction among the established parameters. Methods: A retrospective comparative study was undertaken. The 'arytenoid asymmetry angle' formed between skewed 'glottic' and 'interarytenoid' axes (traced along the plane of closure of the membranous and cartilaginous glottis, respectively) was quantified in pre-operative laryngoscopic images of 85 adults with unilateral vocal fold paralysis who underwent either type 1 thyroplasty (group 1) or type 1 thyroplasty with arytenoid adduction (group 2). The need for arytenoid adduction was determined intra-operatively based on subjective voice improvement and laryngoscopic results. Results: Arytenoid asymmetry (p < 0.0001), posterior phonatory gap (p = 0.001) and vertical level difference (p = 0.004) were significantly greater in group 2 (descending order of parameters). Arytenoid asymmetry angle showed a significant positive correlation with the latter two parameters. Conclusion: Arytenoid asymmetry is the most predictive parameter for arytenoid adduction. An arytenoid asymmetry angle of more than or equal to 33.9⁰ is an indication for arytenoid adduction. This aids in pre-operative planning of arytenoid adduction. [ABSTRACT FROM AUTHOR]

Objective: To evaluate voice intensity as the primary outcome measurement when treating unilateral vocal fold paralysis patients. Methods: This prospective observational study comprised 34 newly diagnosed unilateral vocal fold paralysis patients undergoing surgical interventions: injection laryngoplasty or medialisation thyroplasty. Voice assessments, including maximum vocal intensity and other acoustic parameters, were performed at baseline and at one and three months post-intervention. Maximum vocal intensity was also repeated within two weeks before any surgical interventions were performed. The results were compared between different time points and between the two intervention groups. Results: Maximum vocal intensity showed high internal consistency. Statistically significant improvements were seen in maximum vocal intensity, Voice Handicap Index-10 and other acoustic analyses at one and three months post-intervention. A significant moderate negative correlation was demonstrated between maximum vocal intensity and Voice Handicap Index-10, shimmer and jitter. There were no significant differences in voice outcomes between injection laryngoplasty and medialisation thyroplasty patients at any time point. Conclusion: Maximum vocal intensity can be applied as a treatment outcome measure in unilateral vocal fold paralysis patients; it can demonstrate the effectiveness of treatment and moderately correlates with self-reported outcome measures. [ABSTRACT FROM AUTHOR]

Objective: This study investigated the position of adduction thread attachment, pulling direction and fixation position in revision arytenoid adduction surgery performed in two patients with left vocal fold palsy in whom satisfactory speech improvement had not been obtained by arytenoid adduction and type 1 thyroplasty. Methods: Revision arytenoid adduction surgery was performed with the vocal fold in the midline position in both cases. A type 1 thyroplasty procedure was subsequently added in one case because of worsened quality of speech following arytenoid adduction. Results and conclusion: Although the arytenoid adduction procedure is conceptually well established, there is still room for debate concerning the actual surgical procedures used. The technique described in this report is effective, suggesting that it is worthy of recognition as an index procedure. [ABSTRACT FROM AUTHOR]

Background: In order to improve a large posterior glottal gap and/or aspiration, injections of augmentation substances should not only be administered at the mid-membranous vocal fold in the thyroarytenoid muscle, but also at the cartilaginous portion of the vocal fold to make adduction arytenopexy possible. Method: Ten adult human larynges were investigated using the whole-organ serial section technique. Results: Vertical thickness of the posterior aspect of the thyroarytenoid muscle was relatively thin (3.4 ± 0.4 mm), especially in females (3.2 ± 0.3 mm). Consequently, care should be taken to ensure the correct depth of needle placement. If the needle is placed too deep, augmentation substances are injected into the lateral cricoarytenoid muscle, located beneath the thyroarytenoid muscle, or into the paraglottic space, located inferolateral to the thyroarytenoid muscle. Conclusion: The injection location and the amount of injected material should be modified based on the pathological conditions of the voice disorder and aspiration. [ABSTRACT FROM AUTHOR]

Background: Medialisation thyroplasty is considered the ‘gold standard’ treatment for unilateral vocal fold paralysis, enabling improvement of voice and swallowing function, and preventing life-threatening aspiration events. The most commonly used laryngeal implants induce some degree of local tissue inflammatory response, and carry the risk of immediate or delayed implant extrusion. Methods: This paper describes a novel approach for medialisation thyroplasty. Specifically, it utilises a ribbon of autologous tensor fascia lata harvested at the time of surgery. This is layered within the paraglottic space in a manner similar to Gore-Tex thyroplasty. Results: Thus far, this method has been accomplished in two patients with unilateral vocal fold paralysis, who also received prior radiotherapy to the head and neck. Conclusion: Given the increased risk of post-operative wound breakdown and infection in irradiated patients, it is suggested that this new approach will lead to improved outcomes, and a decrease in complications such as extrusion or wound infection, particularly in this patient population. [ABSTRACT FROM AUTHOR]

Objective:To conduct a cost analysis of injection laryngoplasty performed in the operating theatre under local anaesthesia and general anaesthesia.Methods:The retrospective study included patients who had undergone injection laryngoplasty as day cases between July 2013 and March 2016. Cost data were obtained, along with patient demographics, anaesthetic details, type of injectant, American Society of Anesthesiologists score, length of stay, total operating theatre time and surgeon procedure time.Results:A total of 20 cases (general anaesthesia = 6, local anaesthesia = 14) were included in the cost analysis. The mean total cost under general anaesthesia (AU$2865.96 ± 756.29) was significantly higher than that under local anaesthesia (AU$1731.61 ± 290.29) (p < 0.001). The mean operating theatre time, surgeon procedure time and length of stay were all significantly lower under local anaesthesia compared to general anaesthesia. Time variables such as operating theatre time and length of stay were the most significant predictors of the total costs.Conclusion:Procedures performed under local anaesthesia in the operating theatre are associated with shorter operating theatre time and length of stay in the hospital, and provide significant cost savings. Further savings could be achieved if local anaesthesia procedures were performed in the office setting. [ABSTRACT FROM PUBLISHER]

Background:Parkinson's disease is a degenerative disorder of the central nervous system, mainly affecting motor functions including the voice. The aetiology of dysphonia changes throughout the course of disease progression.Objectives:This study aimed to determine the laryngeal changes seen in early-, mid- and late-stage Parkinson's disease. Thirteen patients with Parkinson's disease are presented, representing the largest series of voice patients with Parkinson's disease seen in a voice clinic in the literature.Method:Age, gender, severity of handicap caused by voice disorder and possible associated reflux symptoms were examined.Results:Laryngeal function appeared to change gradually with progression of the disease, and may have been affected by the presence of pre-existing laryngeal pathology.Conclusion:Laryngeal function in Parkinson's disease appears to go through a series of changes that may be helped by both therapeutic and surgical interventions. These patients should be treated within the confines of a voice clinic multidisciplinary model. [ABSTRACT FROM AUTHOR]

It has been 100 years since Erwin Payr first developed an operation to improve the effects of a paralysed vocal fold, and operations based on this technique are still in use today. This technique, medialisation thyroplasty, aims to improve the symptoms caused by vocal fold palsy by realigning the lateralised vocal fold into the midline.Whilst the effects of vocal fold palsy were recognised in antiquity, it was only with the development of indirect laryngoscopy in the late nineteenth century that the vocal fold paralysis could be identified as an aetiology for poor phonation and dysphagia. Payr, in 1915, was the first to perform a recognisable form of medialisation thyroplasty, which was further developed in the early twentieth century, but medialisation thyroplasty did not begin to be widely used until the development of the modern technique by Isshiki et al., in 1974.Since then, medialisation thyroplasty has continued to be developed and is currently the most widely used technique for correcting the effects of vocal fold palsy. However, a wide array of therapeutic options is now available for vocal fold palsy and it is impossible to say whether or not medialisation thyroplasty will still be used in another 100 years. [ABSTRACT FROM AUTHOR]

Objective:To develop an ovine model for teaching suspension laryngoscopy and phonosurgery.Methods:The head and neck from 10 pre-pubescent sheep were harvested following humane euthanasia at the end of an in vivo protocol. No live animals were used in this study. The tissues were saline-perfused and refrigerated for 1–5 days. Suspension laryngoscopy was performed using adolescent Parsons and adult Kantor-Berci laryngoscopes suspended with a Benjamin-Parsons laryngoscope holder. Visualisation was achieved with 0° and 30° telescopes, and a three-chip camera and video system. Shapshay-Ossoff microlaryngeal instruments were used for endolaryngeal dissection.Results:Experienced laryngologists led a second year medical student through several procedures including injection laryngoplasty, hydrodissection and incision, endolaryngeal suturing, and partial cordectomy. Despite expected anatomical differences, the model proved highly realistic for suspension microlaryngoscopy.Conclusion:The sheep head and neck model provides an inexpensive, safe model for developing skills in suspension laryngoscopy and basic phonosurgery. [ABSTRACT FROM PUBLISHER]

Objectives:To explore unilateral vocal fold paralysis patients' perception of a proposed randomised, controlled trial of laryngeal reinnervation versus thyroplasty, and to identify patients' concerns regarding their voice.Methods:Seventeen patients from five voice clinics in London were identified as being eligible for the randomised, controlled trial. Eleven of these patients (9 females and 2 males; age range, 18–65 years) were interviewed using a semi-structured topic guide (they were given a minimum of 2 weeks to read through the study information sheet). The interviews were recorded, transcribed and analysed using thematic analysis.Results:The patients were satisfied with the clarity of the information sheet. Most of them perceived that reinnervation was a more ‘attractive’ option than thyroplasty. This may have been the result of certain phraseology used in the information sheet and by recruiters. Patients' main concern was reduced voice strength and the effects of this on work and social life.Conclusion:Phraseology that needed changing was identified; these changes may optimise the recruitment process for a trial. We propose using the voice handicap index 10 as the primary measure of outcome in the proposed randomised, controlled trial. [ABSTRACT FROM PUBLISHER]

AbstractObjective:The surgical treatment of intractable aspiration usually requires sacrifice of the patient's natural voice to prevent food entering the airway. Biller described a tubed supraglottic laryngoplasty to control aspiration while allowing patients to phonate with their larynx. Our preliminary experience with this technique in Chinese patients has been disappointing, as tension in the mucosa on wound closure led to wound dehiscence. Our objective was to modify Biller's technique in order to achieve a better outcome.Method:We modified Biller's technique by trimming the epiglottic cartilage and by inserting a tibial periosteal graft to reinforce closure of the mucosa, creating an arrangement resembling a Chinese steam boat.Results:Three Chinese patients underwent the modified Biller's technique. No wound dehiscence occurred, the surgery controlled aspiration, and the patients were able to phonate with their own larynx. All patients resumed oral feeding, and previously placed gastrostomy tubes were removed.Conclusion:The ?steam-boat? supraglottic laryngoplasty is a viable surgical alternative to total laryngectomy or tracheal diversion for controlling intractable aspiration, and preserves a phonating larynx. [ABSTRACT FROM AUTHOR]

AbstractObjectives:Vocal cysts with fold atrophy often result in more severe glottal incompetence than vocal cysts along during phonation. Although total excision or marsupialisation are reliable treatments for vocal fold cysts, any post-operative vocal deficit with significant glottal gap will need further treatment. This study aimed to evaluate the efficacy of combined treatment consisting of marsupialisation of the cyst immediately followed by strap muscle transposition laryngoplasty.Method:Under direct laryngomicroscopy, microscissors were used to make a disc-shaped incision encircling the equator of the cyst. After marsupialisation of the cyst, a simultaneous medialisation laryngoplasty with strap muscle transposition was performed.Results:Seven patients with vocal cysts and marked vocal fold atrophy were included in the study. After surgery, subjective improvement in voice quality was reported by all patients. Patients' glottal incompetence and vocal performance were markedly improved.Conclusion:Marsupialisation is a simple and effective surgical technique for vocal fold cysts. For cases of vocal cysts with marked vocal fold atrophy, marsupialisation followed by medialisation laryngoplasty with strap muscle transposition may be considered. [ABSTRACT FROM AUTHOR]

Objective: To evaluate differences between the functional results of framework surgery and autologous fat injection laryngoplasty, for patients with unilateral vocal fold paralysis. Study design: Sixty-two patients underwent framework surgery, while 64 received autologous fat injection laryngoplasty. Voice function before and after both procedures was assessed using aerodynamic and acoustic analysis, with differences evaluated using paired t-test in both groups. Results: In both groups, all parameters improved significantly after surgery, compared with before surgery. Post-operative improvement in all parameters was significantly greater after fat injection laryngoplasty, compared with framework surgery. Conclusion: Autologous fat injection laryngoplasty was thus found to be a more effective and reliable therapy for improving voice function in patients with vocal fold paralysis, compared with framework surgery. [ABSTRACT FROM AUTHOR]

Objective: The effectiveness of autologous fat injection laryngoplasty may be reduced by resorption of injected fat tissue. The aim of the present study was to clarify the efficacy of fat injection laryngoplasty using autologous fat plus a replication-defective adenoviral vector expressing hepatocyte growth factor, regarding reduction of injected fat tissue resorption. Material and methods: Four female beagle dogs were used in this study. After sedation, a direct laryngoscope was introduced to enable visualisation of the larynx. In each dog, harvested autologous fat plus an adenoviral vector expressing hepatocyte growth factor was injected into the right true vocal fold, and harvested fat plus an adenoviral vector expressing no gene was injected into the left true vocal fold. A total laryngectomy was performed one year after the intracordal fat injection. Coronal sections of the resected whole larynges were made and the following parameters assessed using light and electron microscopy: size of fat area; number of vasculoendothelial cells surrounding adipocytes; and shape of injected adipocytes in the vocal fold. Results: The fat area was significantly larger and the number of vasculoendothelial cells surrounding adipocytes significantly greater in the intracordal fat injection containing adenoviral vector expressing hepatocyte growth factor, compared with the control intracordal fat injection containing adenoviral vector expressing no gene. When viewed under electron microscopy, the injected adipocytes were observed to have grafted better in the intracordal fat injection with hepatocyte growth factor adenoviral vector, compared with the control intracordal fat injection with adenoviral vector expressing no gene. Conclusions: Injection into the vocal fold of autologous fat containing an adenoviral vector expressing hepatocyte growth factor can reduce subsequent resorption of injected fat. [ABSTRACT FROM AUTHOR]

Aim: To compare voice performance following Bioplastique™ injection with that following Isshiki thyroplasty.Measures: A 12 item, self-reported voice performance questionnaire was completed and observer-rated perceptual voice analysis scores were also measured, before and after Bioplastique injection, for 14 patients. Results were compared with our previously reported outcomes for 28 thyroplasty patients.Results: Only 14 of 30 patients had complete datasets. For these patients, the mean pre-operative voice performance questionnaire score improved significantly, from 40.3 to 18.9 (p=0.002, Wilcoxon test). All perceptual analysis parameters showed significant improvement. These results compare favourably with the thyroplasty cohort (mean voice performance questionnaire score: pre-operative 35; post-operative 18; p<0.001). One Bioplastique patient developed contralateral paresis, requiring partial removal of the material 18 months later. Two thyroplasty patients experienced complications and three required revision.Conclusions: Both Bioplastique injection and Isshiki thyroplasty resulted in a significant improvement in both subjective and perceptual voice performance. Our data suggest that the effect size of the two interventions is approximately similar (in nonrandomised cohorts of surviving patients). As in many similar studies, the incomplete follow-up data reflect severe comorbidity. Bioplastique injection is a quicker procedure associated with fewer complications, and thus appears superior to framework surgery in patients with limited life expectancy. [ABSTRACT FROM AUTHOR]

Introduction:Hoarseness is common and can have a major impact on patients’ quality of life. We report a rare case of hoarseness secondary to haemodialysis.Case report:A 62-year-old man described developing transient hoarseness after haemodialysis sessions, which he underwent three times weekly. Fibre-optic nasendoscopy showed incomplete glottis closure due to bowing of the vocal folds. A computed tomography scan of the neck and thorax was unremarkable. Speech therapy was unhelpful. The renal physicians concluded that no change could be made to his dialysis regime. The patient subsequently underwent injection laryngoplasty with calcium hydroxylapatite, with marked improvement of his symptoms.Discussion:A literature search found one relevant article reporting that 60 per cent of patients suffered post-dialysis hoarseness and decreased vocal fold thickness. It is postulated that dialysis causes dehydration of Reinke's space, affecting vocal fold thickness and the patient's voice.Conclusion:Hoarseness caused by haemodialysis is uncharted territory. Further research is required to determine its prevalence and contributing factors. [ABSTRACT FROM PUBLISHER]

Objective:To compare clinical outcomes and complication rates in patients undergoing injection laryngoplasty performed under local versus general anaesthesia.Methods:A retrospective review was conducted of patients who underwent injection laryngoplasty performed by a single laryngologist in a tertiary Australian laryngology centre, between February 2013 and December 2014. Patient demographics, anaesthetic modality and complications were recorded. Voice Handicap Index 10 and the Grade, Breathiness, Roughness, Asthenia, Strain scale were evaluated.Results:Thirty-four laryngoplasties were performed under general anaesthesia and 41 under local anaesthesia, with mean patient ages of 59.5 and 68.8 years, respectively. Voice Handicap Index 10 scores were significantly improved post-injection (p < 0.001), with no significant difference between general anaesthesia and local anaesthesia (p > 0.05). All aspects of the Grade, Breathiness, Roughness, Asthenia, Strain scale showed significant improvement post-injection, except asthenia. There were seven (9.3 per cent) minor complications (five in the general anaesthesia group, two in the local anaesthesia group), all managed conservatively.Conclusion:Injection laryngoplasties performed under general anaesthesia and local anaesthesia offer similar voice outcomes, with comparable complication rates. Hence, development of a management algorithm for injection laryngoplasties performed under local anaesthesia is recommended. [ABSTRACT FROM PUBLISHER]