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Objectives/Hypothesis: The purpose of this study was to compare the clinical effectiveness of type I thyroplasty, injection laryngoplasty, and graft implantation for the treatment of vocal fold scar and pathologic sulcus vocalis. Study Design: Prospective, multi-arm, quasi-experimental research design.Methods: Twenty-eight patients with newly diagnosed vocal fold scar and/or pathologic sulcus vocalis were assigned to one of three treatment modalities: type I thyroplasty (n ¼ 9), injection laryngoplasty (n ¼ 9), and graft implantation (n ¼ 10). Psychosocial, auditory perceptual, acoustic, aerodynamic, and videostroboscopic data were collected pretreatment and at1, 6, 12, and 18 months posttreatment. Results: Type I thyroplasty and graft implantation both resulted in reduced voice handicap with no concomitant improvement in auditory-perceptual, acoustic, aerodynamic, or vocal fold physiologic performance. Injection laryngoplasty resulted in no improvement on any vocal function index. Patients who underwent graft implantation exhibitedthe slowest improvement trajectory across the 18-month follow-up period. Conclusions: A persistent challenge in this area is that no single treatment modality is successful for the majority of patients, and there is no evidence-based decision algorithm for matching a given treatment to a given patient.Progress therefore requires the identification and categorization of predictive clinical features that can drive evidence-based treatment assignment. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: To measure the laryngeal resistance (RL), subglottal pressure (Ps), and mean flow rate (MFR) of adductor (ADSD) and abductor (ABSD) spasmodic dysphonia patients using the airflow interrupter. Methods: The RL of six ABSD and seven ADSD patients was measured using the airflow interrupter, a noninvasive device designed to measure MFR and Ps via mechanical balloon valve interruption. Subjects performed 10 trials at each of two intensity levels, with each trial consisting of a sustained /a/ during which phonation was interrupted for 500 ms. Laryngeal resistance was calculated as subglottal pressure divided by airflow. Results: Mean RL for the ADSD and ABSD subtypes at 65 dB were 24.78 cmH2O/L/s and 14.51 cmH2O/L/s, respectively ( P = .04). Mean RL at 70 dB were 40.02 cmH2O/L/s and 15.84 cmH2O/L/s ( P = .014). Ps for the ADSD and ABSD subtypes at 65 dB were 10.23 cmH2O and 8.32 cmH2O, respectively ( P = .582). At the 70 dB level, Ps were 12.39 cmH2O and 11.78 cmH2O ( P = .886). MFR for the ADSD and ABSD subtypes at 65 dB were 435 mL/s and 746 mL/s ( P = .205). Mean MFR at 70 dB were 518 mL/s and 848 mL/s ( P = .198). Conclusions: Noninvasive measurements of RL may be useful for differentiating between ADSD and ABSD. This simple objective test, which produces a quantitative output, could be used to evaluate laryngeal function in patients with spasmodic dysphonia. Laryngoscope, 2009 [ABSTRACT FROM AUTHOR]

Hypothesis: Posterior positioning of medialization thyroplasty provides the best acoustic and aerodynamic outcomes. Study Design: Ex vivo excised canine larynx. Methods: Unilateral thyroplasty windows were cut in the thyroid cartilages of 10 excised canine larynges. Each larynx was mounted on an artificial lung and the vocal fold opposite the thyroid window was adducted by medializing its arytenoid cartilage. Then, medialization thyroplasty was simulated with a probe placed anterior, central, and posterior in the thyroid window. The glottal area, airway reduction, medialization force, phonation threshold pressure and flow, aerodynamic power, intensity, efficiency, jitter, shimmer, and signal-to-noise ratio (SNR) were measured at each medialization position. Results: Posterior medialization probe placement minimized the glottal area, provided the best voice as determined by perturbation measures and SNR, reduced the work of phonation, and increased efficiency. Anterior and middle probe placement minimized the work of phonation but provided only modest gains in sound quality and decreased sound intensity. Medializing the vocal fold with posterior probe placement required twice as much force as central and anterior probe placement. Conclusions: The results suggest that posterior medialization provides the greatest improvement in acoustic parameters and efficiency in patients who can tolerate the airway reduction. Middle and anterior medialization can decrease work of phonation, but in this experiment objective improvement in sound quality was limited. Subtle changes in displacement shim contour, especially in middle and anterior locations, have a substantial impact on voice outcome, affirming the value of intraoperative voice assessment. Laryngoscope, 119:591-596, 2009 [ABSTRACT FROM AUTHOR]

Science advances occur through orderly steps, puzzle-solving leaps, or divergences from the accepted disciplinary matrix that occasionally result in a revolutionary paradigm shift. Key advances must overcome bias, criticism, and rejection. Examples in biological science include use of embryonic stem cells, recognition of Helicobacter pylori in the etiology of ulcer disease, and the evolution of species. Our work in vocal fold restoration reflects these patterns. We progressed through phases of tissue replacement with fillers and biological implants, to current efforts at vocal fold regeneration through tissue engineering, and face challenges of a new 'systems biology' paradigm embracing genomics and proteomics. [ABSTRACT FROM AUTHOR]

Objectives: Nearly one third of patients with idiopathic Parkinson's disease (IPD) cite dysphonia, characterized subjectively as causing a harsh and breathy voice, as their most debilitating deficit. Medical or behavioral treatments may lead to voice improvement. The purpose of this study was 1) to determine whether vocal fold injection of Cymetra (micronized form of collagen, elastin, proteoglycans; Lifecell Co.) is associated with changes in dysphonic voice characteristics in subjects with IPD, as judged perceptually using a standard instrument Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), and (2) which acoustic and aerodynamic measurements of voice are most reflective of any observed perceptual changes in voice. Study Design: Prospective clinical evaluation of patients with Parkinson's-related dysphonia (PRD). Methods: Six patients with PRD were evaluated before treatment for the presence of dysphonia and glottal gap. All subjects underwent transoral vocal fold collagen injection using topical anesthesia in the otolaryngology clinic as part of their clinical care. At the initial clinic visit, and 10 to14 days after vocal fold collagen injection, patients were asked to complete the Voice Handicap Index (VHI), a questionnaire concerning voice-related quality of life, and perceptual analyses of voice quality were performed. In addition, patients underwent acoustic (pitch/loudness range, maximum phonation time [MPT], and aerodynamic phonation threshold pressure [PTP]) voice analysis. Results: Five of six subjects had self-perceived improvements in voice after treatment, as determined by the VHI (range, +8 to −24). All five subjects who completed testing demonstrated decreased PTP (range, −1.3 to −2.7, P = .002). Five of six subjects demonstrated statistically significant improvements in MPT (range, −2-16 s, P = .05). Five of six subjects had improved pitch range (−26-343 Hz), whereas all subjects had increased intensity range (0.6-23 db) after injection. Conclusions: Transoral collagen injection in patients with PRD is safe, well tolerated, and is an effective temporary method of subjectively improving voice and speech in selected patients with IPD. Reduction of glottal gap with collagen improves MPT and subglottal PTP. The resulting gain of vocal efficiency may reduce vocal fatigue and provide a useful adjunct to voice therapy for PRD. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: It has been reported that in aged vocal folds, dense collagen deposition takes place and hyaluronic acid decreases in the lamina propria, which are thought to contribute to the vocal problems occurring with age (presbyphonia). To restore aged vocal folds to their younger state, it seems crucial to address these age-related lamina propria changes. Intervention that might increase hyaluronic acid and decrease collagen would appear to be a potentially useful approach. The present study examined the effects of growth factors on aged fibroblasts in terms of the production of hyaluronic acid and collagen type I.Study Design: In vitro study using animal model.Methods: Fibroblasts were harvested from young and aged rat vocal folds and cultured with or without hepatocyte growth factor and/or basic fibroblast growth factor at different concentrations. Subsequently, the production of hyaluronic acid and collagen type I was examined in the supernatant culture media using enzyme-linked immunosorbent assay.Results: Aged fibroblasts produced less hyaluronic acid than younger fibroblasts. When aged and young fibroblasts were cultured with basic fibroblast growth factor, hyaluronic acid production increased and collagen type I production decreased regardless of the concentration, whereas the effects of hepatocyte growth factor appeared to vary with concentration. The basic fibroblast growth factor also was associated with stimulation of growth of aged fibroblasts.Conclusion: The present results suggest that growth factors, especially basic fibroblast growth factor, may have therapeutic potential in restoration of aged vocal fold. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Vocal fold scarring disrupts the layer structure of the vocal fold lamina propria that is essential for optimal mucosal vibration. Prevention of vocal fold scarring remains challenging. Hepatocyte growth factor (HGF) has strong antifibrotic activity. The authors' previous studies have found that HGF stimulates hyaluronic acid production and suppresses collagen production from vocal fold fibroblasts, suggesting that HGF has therapeutic potential in prevention of vocal fold scarring. The present study aimed to demonstrate the effects of HGF on vocal fold scarring in an in vivo rabbit model.Study Design: Animal experiment.Methods: The vocal fold mucosa was stripped unilaterally in 20 rabbits, then HGF or saline (sham-treated group) was immediately injected into the injured site. At 6 months after the procedure, histological, rheological, and physiological examinations of vibratory behavior were completed.Results: Histological examination revealed excessive collagen deposition and disorganized elastin in the sham-treated group, whereas the HGF-treated group presented with better wound healing exhibiting less collagen deposition. Contraction of the injured vocal folds observed in the sham-treated group did not occur in the HGF-treated group. Rheological data indicated that the HGF-treated vocal folds were less stiff and viscous compared with the sham-treated group. Mucosal vibration of HGF-treated vocal folds appeared much better than the sham-treated group in terms of phonation threshold pressure, vocal efficiency, mucosal wave amplitude, and glottal closure.Conclusion: Hepatocyte growth factor proved to be useful in preventing vocal fold scarring and maintaining viscoelastic shear properties of the vocal fold. [ABSTRACT FROM AUTHOR]

Scientific discovery, technological advances, and improved outcomes assessment have resulted in advances and refinements in phonosurgery. Three areas of substantial evolution are phonomicrosurgery, laryngeal framework surgery, and the use of implantable materials in vocal folds. Discovery of the importance of the superficial layers of the lamina propria has led to increased use of more limited medial microflap approaches and less frequent use of the classic lateral cordotomy flap approach. Alternative approaches to managing vocal fold scarring defects have addressed the separation of body and cover and provided suitable lamina propria replacement. Approaches to sulcus vocalis have been refined to address type II (linear vergeture) and type III (focal invasive pit) sulcus, where there is loss of lamina propria, while still recognizing the common nonpathological type I (physiological) sulcus. Technological advancements such as photodynamic therapy, tuned dye lasers, and laryngeal microdebridement have augmented the armamentarium for mechanical removal of laryngeal papillomata. Careful infusion-assisted microexcision and adjunctive medical management have been refined and made more effective. Laryngeal framework surgery has embraced the development of Silastic, hydroxylapatite, expanded polytetrafluoroethylene, and titanium shims. Anatomical studies have helped to improve operative precision and safety, and have led to inventive variations in arytenoid repositioning that improve closure of the posterior subunit. Vocal fold augmentation by injection has been facilitated by innovative use of the rigid telescope and intraoperative videostroboscopy. Anatomical studies have focused on the infrafold region and rheological studies have attempted to match viscoelastic properties of injectable substances to those of vocal fold tissues. Alloplastic materials such as Teflon have been largely supplanted by newer bioimplantables such as fat, collagen, and fascia. [ABSTRACT FROM AUTHOR]

This is a report of the histologic findings in a human larynx that had undergone collagen injection for glottic insufficiency 14 months prior to autopsy. The patient's management before augmentation with collagen included extended supraglottic laryngectomy, radiation therapy, and Polytef injection. Connective tissue changes secondary to other forms of treatment were apparent bilaterally and changes limited to the site of collagen injection were identified. There have been reports of persistence of injected collagen in the canine larynx at 1 year but this is the only study documenting persistence in a human subject. The implant appeared homogeneous and was easily distinguished from host collagen and the reactive fibrosis associated with particulate Polytef. These findings are similar to those observed in the canine model and suggest that there is persistence of injected collagen in the human larynx. [ABSTRACT FROM AUTHOR]

Collagen is an essential component of the functionally important layered structure of the vocal cord. Soluble bovine collagen appears to be suitable for injection into vocal folds to correct glottic insufficiency. Clinical trials and preliminary laboratory studies with the canine larynx indicate that injectable collagen is safe, effective, easily injected, and well-tolerated. Bovine collagen softens scar tissue, attracts the ingrowth of host fibroblasts, and allows the eventual replacement of the implant by new host collagen. This study examines the fate of collagen injected into canine vocal folds. Two forms of soluble bovine collagen, differing only in the amount of chemically induced cross-linkage, were injected into vocal folds of dogs; the animals were then killed at 12-week intervals for 1 year. Gross and histologic examination showed that both substances tended to be resorbed when injected deeply in the vocalis muscle, but persisted when injected in the plane of the vocal ligament - a site normally composed of dense collagen. The invasion of the implant by active host fibroblasts and the secondary deposition of new host collagen were evident in histologic sections. Examination with polarized light confirmed the presence of birefringence characterizing host collagen. The invasion of fibroblasts and deposition of new collagen in the implant were seen with electron microscopy. Cellular invasion seemed to progress more rapidly in the cross-linked preparation. Injected collagen did not evoke a foreign body reaction in any specimen studied, and was well-tolerated during replacement by host tissue. [ABSTRACT FROM AUTHOR]

Injectable collagen appears to be safe and effective in treating glottic insufficiency. Fifty-four patients received vocal-fold injections of Zyderm Collagen Implant and their responses were followed for as long as 2 years. Videostroboscopy affords the best assessment of glottic function and correlates well with vocal quality. Maximum phonation time and transglottic airflow are the most sensitive measures of glottic efficiency; follow-up studies indicate that responses to treatment vary at 1 week, tend to stabilize by 3 months, and show only slight decrement over 1 year. One patient experienced a delayed hypersensitivity reaction, but it did not adversely affect his result. The use of cross-linked preparations of collagen should decrease the incidence of such responses. Treated patients were divided into diagnostic groups. Patients with bilaterally scarred vocal folds did not appear to respond optimally to collagen injection. Vocal rehabilitation was better if patients had at least one normal vocal fold. The best results occurred in patients with unilateral vocal fold paralysis and pre-existent bowing or atrophy did not affect these results. Collagen should be injected in the plane of the vocal ligament for best results; if the injection is too deep the implant is resorbed, and if too superficial, vocal-fold vibration is impaired. [ABSTRACT FROM AUTHOR]

Glottic insufficiency has been successfully managed by Teflon augmentation of paretic vocal cords over the past two decades. Collagen fulfills the criteria for a suitable bioimplant and is an attractive alternative as it is a normal constituent of the extracellular protein matrix. This study explores the use of modified bovine collagen injected into the canine larynx. Clinical situations are simulated by creating lesions and injecting collagen at different sites. The technique permits precise placement and quantification. Histologic study of the collagen implant fails to show evidence of significant foreign body reaction. The injected collagen appears similar to viable connective tissue and is colonized by host fibroblasts and nourishing capillaries. [ABSTRACT FROM AUTHOR]

Meningioma is the most common tumor of the central nervous system, but it has only been reported in 79 patients to involve the temporal bone. The 4 cases presented here show striking clinical similarity to a subgroup of 20 meningiomas reported to be entirely intratympanic; however, in each instance the extent, origin, and potential of the disease was not initially evident. Precise histopathologic diagnosis may be aided by electron microscopy. Current concepts of embryology lend credence to the possible role of arachnoid endothelial cells in the pathogenesis of intratympanic meningioma. An advanced intracranial meningioma may be overshadowed by the hearing loss, tinnitus, and otalgia calling attention to an intratympanic component. The clinician should remain suspicious of intracranial disease even after excision of an apparently well circumscribed intratemporal lesion. Progessive sensorineural hearing loss and persistent otalgia portend recurrent or intracranial disease. Follow-up for at least 10 years with judicious use of CT scans is suggested. [ABSTRACT FROM AUTHOR]

Objective: Botulinum toxin (BT) is a currently used treatment for spasmodic dysphonia (SD) and other related focal dystonias. The goal of this study is to provide a basis for using the rat larynx to objectively assess physiological and histological effects of BT.Study Design: Dosages and volumes of BT injection were varied and three physiological parameters were measured. These measures included: optical density of PAS-stained laryngeal muscle after electrical stimulation, which is an indirect measure of denervation, spontaneous laryngeal muscle activity, and laryngeal movement.Methods: A new microlaryngoscopic technique was developed, which made it possible to observe and manipulate the rat larynx endoscopically. Laryngeal movement and electromyographic (EMG) measures were made prior to injection and 3 days following BT injections of various dosages and volumes. Optical density measures were made 3 days after injection.Results: Significant reductions in vocal fold motion and spontaneous laryngeal muscle activity as a function of increased BT dosage were observed. In addition, the optical density of PAS-stained laryngeal muscle after electrical stimulation was increased following BT injection. Significant volume effects in optical density were observed in the lateral thyroarytenoid and lateral cricoarytenoid muscles on the contralateral side.Conclusions: The rat laryngeal model is suitable for assessing BT effects. In addition, the three physiological variables provided useful and reliable measures of laryngeal function. It is the authors' intention to use the rat laryngeal model to further examine the physiological and histological effects of BT with the goal of developing new methods for the treatment of patients with SD and other focal dystonias. [ABSTRACT FROM AUTHOR]

Objectives: To characterize the acute and chronic cellular effects of botulinum toxin (BT) injection into rat laryngeal muscles. A complete characterization of these effects is important because patients with focal dystonias of the head and neck are commonly treated with BT injection. Further, potential muscular changes in the larynx must be carefully delineated owing to the critical phonatory and airway protective functions of these muscles.Study Design: The acute and chronic cellular effects of BT injection were studied using 5'-bromo 2'-deoxyuridine (BrdU) following single and repeated BT injection into rat laryngeal muscles. BrdU is incorporated into mitotically active nuclei such that changes in cell proliferative behavior following BT injection can be monitored.Results: Increased mitotic activity was detected in the tissue samples studied following BT injection. Differences in the times of the peak distribution of BrdU-labeled cells in each laryngeal muscle were observed. This may be related to the diffusion effects of BT. Prolonged muscle fiber changes, including splitting, were also observed as the result of repeated BT injection.Conclusions: The results of this study suggest that BT may induce a proliferative response in muscle tissue. [ABSTRACT FROM AUTHOR]

Observations and analysis of glottal characteristics are critical in choosing the best modality for surgery in patients with unilateral vocal fold paralysis (UVP). This study suggests that multiple glottal characteristics influence the vocal product in patients with UVP. In addition to the horizontal position of the paralyzed vocal fold (deviation from the midline), the glottal area, degree of bowing of the paralyzed and contralateral vocal folds, maximum separation between vocal folds, compensatory glottal maneuvers, and the vertical glottic closure plane significantly influenced the quality of the voice. Clinicians should be aware of these observations to facilitate treatment planning and assessment of the results of surgical procedures used to improve voice quality in cases of UVP. [ABSTRACT FROM AUTHOR]

This preliminary study reports the first use of injectable autologous collagen for vocal fold augmentation. In previous studies, the authors showed cross-linked bovine collagen to be effective in more than 150 patients with glottic incompetence, particularly those with focal defects or scarred or atrophic vocal folds. However, concerns about possible adverse immunologic responses to the bovine material have limited its use. The authors studied eight patients with difficult vocal fold pathology, including sulcus vocalis, atrophy, and scarring secondary to trauma and cordectomy. Skin was harvested under local anesthesia, processed into a naturally cross-linked injectable form (Autologen®), and injected using indirect laryngoscopy. Voice production was evaluated prior to the injection and at intervals after the injection, using subjective, perceptual, aerodynamic, acoustic, and videostroboscopic assessments. The results indicate that autologous collagen is comparable to injectable bovine collagen in the management of several difficult glottic insufficiency problems and that the likelihood of a hypersensitivity response is negligible. Unlike bovine collagen preparations, Autologen does not require breakdown of the natural collagen molecule, so it is anticipated that this material will be better tolerated and more stable over time. [ABSTRACT FROM AUTHOR]

Historically, clinicians have used subjective assessment and perceptual judgments, supplemented with acoustic measures, aerodynamic studies, and videostroboscopy, to determine the effects of phonosurgery. When phonosurgical results are poor, magnetic resonance imaging (MRI) can be useful in determining how the surgical modifications contributed to the anatomical and functional status of the vocal folds. The authors present examples of MRI following vocal fold medialization by injection, thyroplasty, and arytenoid adduction. Findings reveal that the superior contrast resolution of MRI can precisely identify placement and persistence of injected implants and is particularly helpful in showing effects of the size and shape of alloplastic prostheses on vocal fold displacement. Such information is useful in troubleshooting suboptimal results and in planning revision thyroplasty by defining modification in the design of prostheses and the placement of cartilaginous windows in medialization thyroplasty. MRI can also aid in confirming indications for and limitations of certain procedures. [ABSTRACT FROM AUTHOR]

Vocal fold nodules are a common cause of dys-phonia generally attributed to vocal abuse. Anterior commissure microwebs have been reported as an incidental finding in surgical patients with nodules. In a series of 105 nodule patients evaluated at the University of Wisconsin Clinical Science Center voice laboratory (1987-1992), 11 microwebs were identified. Ten of these microweb patients were among the 20 nodule patients who did not respond to voice therapy and underwent microsurgery. In patients with nodules whose hoarseness is refractory to voice therapy, symptoms that occur early in life suggest the presence of occult vocal fold pathology. Microweb detection requires a high index of suspicion, observation during maximal vocal fold abduction, and clearance of secretions from the anterior commissure. Definitive identification is facilitated by gentle separation of the anterior vocal folds during direct microlaryn-goscopy. The presence of these tiny shelves of tissue might be coincidental, or they might represent another expression of the tissue response to traumatic factors known to produce vocal nodules. We found little difference in vocal function parameters between two similar groups of nodule patients, one with and one without associated microwebs. Further work is needed to determine the significance of microwebs. [ABSTRACT FROM AUTHOR]

The incidental finding of sulcus vocalis in surgical specimens of patients with laryngeal cancer prompted this review. Sulcus deformities were histologically identified in 28 (48%) of 58 whole-mount coronal serial-sectioned laryngeal specimens procured from laryngeal cancer patients. The lesions were analyzed, described, and graded. A control group of 20 larynges, obtained from autopsies of patients without known laryngeal pathology, were similarly processed, and whole-mount histologic sections were studied. Four of these specimens (20%) also demonstrated sulcus deformities. In the control group, the shape and location of the sulci were similar, but the lesions were smaller than in the cancer group. The sulcus lesions revealed chronic inflammation of the subepithelial tissues with vascular ingrowth and fibrosis of the superficial lamina propria (Reinke's space); in the cancer group the sulcus was usually on the opposite vocal fold, where irritation from the tumor might be anticipated. Although the etiology of the sulci remains controversial, these findings suggest that irritation and inflammation might play a role in the pathogenesis of sulcus vocalis. [ABSTRACT FROM AUTHOR]

Abstract: The Neurolaryngology Study Group convened a multidisciplinary panel of experts in neuromuscular physiology, electromyography, physical medicine and rehabilitation, neurology, and laryngology to meet with interested members from the American Academy of Otolaryngology Head and Neck Surgery, the Neurolaryngology Subcommittee and the Neurolaryngology Study Group to address the use of laryngeal electromyography (LEMG) for electrodiagnosis of laryngeal disorders. The panel addressed the use of LEMG for: 1) diagnosis of vocal fold paresis, 2) best practice application of equipment and techniques for LEMG, 3) estimation of time of injury and prediction of recovery of neural injuries, 4) diagnosis of neuromuscular diseases of the laryngeal muscles, and, 5) differentiation between central nervous system and behaviorally based laryngeal disorders. The panel also addressed establishing standardized techniques and methods for future assessment of LEMG sensitivity, specificity and reliability for identification, assessment and prognosis of neurolaryngeal disorders. Previously an evidence-based review of the clinical utility of LEMG published in 2004 only found evidence supported that LEMG was possibly useful for guiding injections of botulinum toxin into the laryngeal muscles. An updated traditional/narrative literature review and expert opinions were used to direct discussion and format conclusions. In current clinical practice, LEMG is a qualitative and not a quantitative examination. Specific recommendations were made to standardize electrode types, muscles to be sampled, sampling techniques, and reporting requirements. Prospective studies are needed to determine the clinical utility of LEMG. Use of the standardized methods and reporting will support future studies correlating electro-diagnostic findings with voice and upper airway function. [Copyright &y& Elsevier]

Objectives: Altered vocal fold anatomy and stiffness associated with sulcus vocalis represent a significant treatment challenge in contemporary phonosurgery. New surgical approaches and implantation materials offer promise in improving vocal fold structure and pliability in this patient population, however, the path toward treatment outcome stability is often long, and eventual treatment outcomes are often varied. We followed 5 of our patients for 18 months following surgical intervention in order to evaluate the success of treatment and compare the utility of perceptual, instrumental, and psychosocial measurement tools.Methods: Patients were enrolled in a larger prospective study designed to collect outcomes data following phonosurgical intervention for sulcus vocalis. Surgery involved cordotomy and implantation of either autologous fascia or an acellular dermal matrix (Alloderm®). Vocal function data (acoustic, perceptual, videostroboscopic, psychosocial) were collected 1–2 weeks before and at 1, 6, 12, and 18 months after surgery.Results: The various vocal function indices demonstrated a general pattern of improvement following intervention; however, variability was observed across indices. The indices appeared to reach stability at different measurement points for different patients. The vocal function data continued to vary as far as 18 months postsurgery.Conclusion: The results suggest that currently available vocal fold implants for sulcus vocalis can result in improved vocal function, and that patients should be followed for at least 18 months following surgical intervention. The different outcome patterns reflected across the various vocal function indices reinforce the importance of using a broad clinical measurement battery, encompassing perceptual, instrumental, and psychosocial tools. [Copyright &y& Elsevier]

Problem: To examine the effectiveness of an auto-crosslinked polysaccharide (ACP) hyaluronan-based gel for the treatment of acute vocal fold scar in a canine animal model.Methods: Twelve canine larynges were injured by unilateral stripping of the vocal fold mucosa, from the epithelium down to the thyroarytenoid muscle. Six of these animals were treated with a transcutaneous injection of ACP gel (30 mg) into the thyroarytenoid muscle and remaining lamina propria at the time of injury, and again at 7 and 14 days postoperatively. The remaining animals were treated with an injection of sodium chloride to serve as sham controls. All animals were euthanized 2 months following the initial treatment. Excised larynx experiments were completed to obtain phonation threshold pressure (PTP) and vocal economy an acoustic output cost ratio (OCR), followed by histologic analysis for hyaluronan and collagen between the scarred and control vocal fold.Results: Dense, thick bundle collagen was observed on the injured side of sham-treated larynges. Minimal collagen deposition was observed on the injured side of ACP-treated larynges. PTP was lower and OCR was higher in the ACP-treated animals.Conclusion: ACP-treated larynges revealed greater ease of phonation and better vocal economy than sham-treated larynges. Collagen deposition was less dense in ACP-treated larynges. ACP gel provided sufficient bulk to the scarred vocal fold.Significance: ACP gel may provide a useful bio-injectable substance for improving rheologic tissue and aerodynamic properties for phonation in the scarred larynx.Support: None reported. [Copyright &y& Elsevier]

Objective: To examine the expressions of fibronectin and other adhesion molecules on the scarred vocal folds in a short- and long-term animal model., Study Design: Animal model., Methods: Six beagles' vocal folds were stripped unilaterally and left untreated. After wounding the vocal folds were harvested from three dogs at 2 months and three dogs at 6 months. The untouched vocal fold was used as a control, and the stripped vocal fold as scarred. Subsequently, the expressions of fibronectin, cadherin, syndecan-1 and syndecan-4 on both vocal folds were examined by immunohistochemical and image analysis., Results: Compared with the control vocal folds, fibronectin significantly increased in the superficial layer of the lamina propria on the scarred vocal folds at both 2 and 6 months. Co-deposition of collagen was observed only at 6 months. Syndecan-4 was significantly overexpressed at the basal layer cells of the epithelium at both 2 and 6 months. No significant expression of either cadherin or syndecan-1 was detected., Conclusions: Scar characteristics at 2 and 6 months are not identical, suggesting that a 2-month period may not be a sufficient to study vocal fold scarring. Adhesion molecules are important in reorganization of extracellular matrix during wound healing because of their binding and adhesion characteristics. The results indicate that fibronectin might be important in providing a scaffold for the deposition of other proteins such as collagen, and the binding characteristics might affect the stiffness of the scarred vocal fold. Prolonged expression of syndecan-4 may reflect the role of focal adhesion during the assembly of scar structure. Ultimately, better understanding of the histological features of the scarred vocal fold might lead to new approaches to treatment.