Management of Vocal Fold Disorders

Educational Objectives

The goal of this program is to improve the management of disorders of the vocal fold. After hearing and assimilating this program, the clinician will be better able to:

1.   Assess the various treatment options for managing voice disorders.

2.   Recommend when and how to use voice therapy to complement vocal fold augmentation.

3.   Employ surgical and technical considerations necessary for minimizing intraoperative errors.

4.   Contrast approaches to managing Reinke’s edema.

5.   Determine which patients require treatment of vocal cord immobility.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Sataloff has commercial relationships with Plural Publications and Medtronic Xomed. Dr. Postma and the planning committee re­ported nothing to disclose. In his lecture, Dr. Sataloff presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgments

Dr. Sataloff was recorded at The Twenty-Ninth Annual James A. Harrill Lecture, held April 24-25, 2009, in Winston-Salem, NC, and presented by the Wake Forest University School of Medicine, Department of Otolaryngology. Dr. Postma was re­corded at Minimally Invasive and Conventional Surgical Management of Thyroid and Parathyroid Disorders, held October 9-10, 2009, in Augusta, GA, and presented by the Medical College of Georgia and University of Pisa. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Vocal Fold Surgery

Robert T. Sataloff, MD, DMA, Professor and Chair, Department of Otolaryngology  – Head and Neck Sur­gery, Senior Associate Dean for Clinical Academic Specialties, Drexel University College of Medicine, and Adjunct Professor, Departments of Otolaryngology  – Head and Neck Surgery, Thomas Jefferson University, the University of Pennsylvania, and Temple University, Philadelphia, PA

Background: voice surgery unlike that of 30 yr ago; in past, procedures largely limited to vocal-fold stripping and laryngectomy; preoperative surgical judgment hardest part; based on comprehensive history, physical ex­amination, detailed strobovideolaryngoscopic analysis of vibratory margins, voice performance measures, and response to voice therapy

Voice therapy: should begin before surgery; patient should be well trained before operation; this protocol im­portant for three reasons: 1) establishes guidelines for patient compliance and educates patient; 2) many pa­tients improve with therapy to degree that negates need for surgery; 3) reinforces to patient that non-surgical options exhausted and surgery necessary only as last resort (thus reducing incentives for patient litigation)

Other patient considerations: patient should decide that present condition bad enough to risk adverse out­comes in hopes of improvement; patient-led decision-making especially important in high-level voice profes­sionals; motivation for therapy  —  in lesions likely to require surgery, schedule surgery at initial visit for 2 to 3 mo later; enroll patient in voice therapy, and see again »2 wk before surgery; if patient improved, surgery can be cancelled

Timing of surgery: patients must be willing and able to comply with postoperative voice restrictions; menstruation  —cases of patients with premenstrual vocal fold hemorrhage; patients at such risk should be operated on mid-cycle; school teachers likely to prefer operation around June

In-office procedures: indirect laryngoscopy effective approach in certain cases; in-office removal of mass done routinely in Germany and Japan with acceptable results; less common in United States

Surgical and technical considerations: ensure hand and arm multi-point stability; surgical instrument should be in contact with laryngoscope; speaker prefers laryngoscopes with triangular design (rather than older, curved designs); prefers sharp-pointed laryngoscope with some lift (helpful when pulling forward anterior commissure); almost all cases also evaluated intraoperatively with zero degree (usually 10-mm) scope to map lesion, and 70-degree scope to inspect vasculature below lesion, determine amount of involvement of vertical face of vibratory margins, and to ensure precision when mapping incision; if office unequipped with 70-de­gree scope, urologist office likely to have one; many procedures can be done under local anesthesia; for cases involving delicate vibratory margin with benign pathology, general anesthesia helpful; cold instruments  —  newer models offer superior degree of delicacy and precision

Nodules: if diagnosis correct and voice team competent, nodules will improve or resolve in 90% of patients; nodule least common mass lesion in speaker’s practice; examination with mirror may seem to reveal nodule, but subsequent examination with stroboscope reveals different condition (eg, cyst on one side, reactive condi­tion on other side); although some conditions unlikely to improve with voice therapy, short course of therapy useful to eliminate hyperfunctional compensation; many lesions require microsurgical intervention; proce­dure should ensure epithelium and superficial layer glide freely over vocal ligament instead of scarred to it

Microflap and mini microflap: make incision in superior surface of vocal fold (eg, when approaching submuco­sal cyst), elevate mucosa, remove cyst submucosally, replace mucosa; speaker designed this technique; now un­derstands it is flawed; procedure can destroy microscopic architecture, resulting in prolonged stiffness even beyond lesion; now prefers so-called mini microflap technique; ensure non-deranged area remains untouched during procedure; incision made at junction of normal and abnormal tissue; combination of (usually) blunt dis­section to elevate mass; use scissors; insert in incision; lean toward glottis; filmy residual superficial lamina pro­pria falls away and preserved; lesion then grasped and resected

Lasers: use on vibratory margin of vocal fold controversial; in expert hands, results potentially comparable to non-laser techniques; guiding physician can correct residents or fellows before incision made with cold in­strument; use of laser in inexperienced hands, however, may result in irreversible damage; tips when using lasers  —  ice vocal folds (potentially prevents thermal spread); make all cuts tangentially; never use laser on “char” setting; with laser, margin of incision should be closer to lesion than with cold instrument incision; if laser incision centered on vibratory margin, ligament may be heated; undersurface of vocal fold  —  lasers can be used; when using mirror, ensure protection of surgeon’s eyes; risk added without substantial benefit

Reinke’s edema: difficulty in deciding whether surgery necessary; some voices abnormal, but may be useful in patient’s occupation (eg, certain singers with signature gravelly voices); Reinke’s edema should not be treated unless disturbing to patient; if patient wants correction, first address underlying issues (eg, smoking, hypothyroidism, voice abuse or misuse) and remove edema

Kleinsasser's approach: superior surface incision; sucking out edema fluid; good in theory, but can be prob­lematic in practice; fluid sometimes difficult to suck out

Bilateral approach: remove edema fluid bilaterally at same sitting; speaker advises against, because 1) inflam­mation can result in extensive webbing, and 2) may result in bilateral vocal fold stiffness; speaker advises doing one side, waiting, ensuring healing and vibration, then potentially doing other side at later time

Papilloma

Revised technique: used in patient with extremely aggressive papilloma; patient later presented with large web; several subsequent procedures failed; patient had some difficulty breathing; speaker had been remov­ing papilloma from patient every few months; speaker then used Prolene suture through 0.02-in piece of Si­lastic as lateral as possible through vocal fold, out other side, back through Silastic, then tied together; procedure completely endoscopic, with no external stitches; technique flaw  —  knots were made in easy-to-tie location, which caused ulcer on contralateral vocal fold; solution  —  knots must be tied in ventricle; tech­nically more challenging, but stitch smoother

Other considerations: microflap useful for carcinoma in situ; adult-onset papilloma often biologically differ­ent disease from aggressive juvenile recurrent respiratory papillomatosis (RRP); cases of complete cure not established; long-term remissions possible; limited RRP, caught early, should be resected as if carcinoma in situ (remove entire papilloma to allow better immune system response); speaker does not use laser for pap­illoma on vocal fold, because 1) repeated procedures result in scarred, stiff vocal fold and damaged voice, and 2) deep and extensive papilloma growth frequently iatrogenic; recommended method  —  use hydrodis­section; elevate flap; resect involved area; save underlying superficial lamina propria; voice results better; use cidofovir; powered shaver  —  useful in certain circumstances (extensive disease, incurable disease in which control of bulk is objective); 3.5 mm at 500 rpm gives control

Carcinoma: best treatment for voice-involved T1 carcinoma unestablished; irradiation probably best for voice results within first yea-r; no supporting evidence for 5 to 10-yr results

Scarring: vibratory margin scar challenging; much scarring inherited from time when vocal fold stripping pop­ular; short-area scars  —  collagen injection of moderate benefit (provoke collagenation and soften preexisting scar); larger scars  —  no optimal approach exists; fat implantation  —  fat implanted in incision will come out; fat implanted in sutured incision will come out through suture holes; solution  —  create access tunnel; make small incision on superior surface; elevate to vibratory margins; insert right-angle instrument through access tunnel; make vertical pocket anteriorly, posteriorly, and inferiorly; sometimes scarring may prevent elevation; more amount of fat inserted, more access tunnel becomes closed (“self-closing trap door”); stuffed area resists falling-out of fat

Update on Managing Vocal Cord Paralysis

Gregory N. Postma, MD, Director, Center for Voice and Swallowing Disorders, and Professor, Depart­ment of Otolaryngology, Medical College of Georgia, Augusta

Vocal fold immobility: uncommon; particularly detrimental to patient quality of life; risks  —  thyroid cancer, Graves’ disease, large goiters, reoperation; combination of causes not uncommon; unilateral vocal fold immo­bility etiologies  —  iatrogenic; neoplasms; most caused by endocrine surgery; thyroid and parathyroid surger­ies account for one-third; bilateral  —  most caused by endocrine surgery

Intraoperative management: depends whether nerve injury planned or unplanned; in planned cases, can em­ploy injection augmentation at conclusion of procedure; retinoid induction  —  done under general anesthesia; easy exposure; place sutures in musculare process; drive through thyroid ala; can do laryngoplasty at follow-up when tightening stitches; primary reinnervation; in case of intraoperative damage to laryngeal nerve, anas­tomosis in ansa cervicalis best option

Future directions: placement of topical agents on nerve endings at time of reanastomosis; enclosure of nerves in tubes to limit reinnervation; animal study showed neurotoxins used intramuscularly could prevent synki­netic reinnervation of muscle; upon severing of laryngeal nerve, inject PCA muscle, thus bringing fibers to TA-LCA complex and bringing vocal cord to midline

Surgical indications: surgery usually unnecessary in patients with glottic insufficiency; indicated in patients with life-altering symptoms (eg, severe dysphonia, aspiration problems [thin liquids or otherwise]), or vocal professionals; watchful waiting reasonable in patients with mild symptoms or who resist surgical option; speech therapy  —  effective in patients with vocal weakness, mild symptoms; 10% to 15% improvement in most cases

Injection laryngoplasty: trend recently away from traditional laryngoplasty toward injections; framework surgery less common; best in thin male patients with good landmarks; easier in immobile rather than paretic vocal folds; injection substances  —  speaker opposes Teflon; various collagen preparations, autogenous fat, fascia temporalis, calcium hydroxyapatite; clinician familiarity, patient condition, and desired response should guide choice of in­jection material; injection site  —  deep and just lateral and anterior to vocal process; superficial injection in para­glottic space contraindicated when performing augmentation; one-third of patients receive second injection in mid vocal fold if fold does not overcorrect sufficiently; method  —  can be done with small endotracheal tube or jet ventilation; peroral administration  —  done with botulinum toxin and steroids, but not recommended in aug­mentations; percutaneous  —  can use sclerotherapy needle through flexible scope with working channel; because of size of dead space, large amount of filler material or chaser needed; botulinum toxin for spasmodic dyspho­nia; cricothyroid technique reasonably simple

External laryngoplasty: externally through thyrohyoid membrane into vocal fold; needle emerges at epiglottic petiole; easily directed into either vocal fold; well tolerated; speaker uses 2-in pediatric spinal needle; local anes­thesia optional; removal of needle unnecessary if patient coughs or gags; must have good visualization with scope

Laryngoplasty: less common; revision rate lower than with injections; method  —  ensure scope easily adjust­able; general anesthesia with propofol; drinking during operation acceptable; close incision with inferior base perichondrial flap; speaker now prefers Gore-Tex over Silastic; bore through thyroid ala with 18-gauge to 20-gauge needle; push needle through and check location with scope; most common mistake is implanting too high; make hole with #15 blade or drill; speaker cuts Gore-Tex himself from cardiothoracic patch Gore-Tex (cheaper than buying pre-cut strips); overcorrect, then close external pericondrium over area to hold in place

Choosing method: injections  —  small to moderate glottic gaps; vocal fold scarring; temporary relief of recurrent nerve injury; fine-tuning after laryngoplasty; inject under general anesthesia for children or adults with control issues; anticoagulant medications not contraindicated; injection likely preferable to external procedure if pa­tient already received irradiation to involved area; sniffing dysphasia; external laryngoplasty  —  larger glottic gaps; improved glottic closure does not always improve swallowing

Suggested Reading

Ada M et al: Congenital vocal cord paralysis. J Craniofac Surg 21:273, 2010; Allen JE et al: Botulinum toxin in the treat­ment of vocal fold nodules. Curr Opin Otolaryngol Head Neck Surg 17:427, 2009; Broniatowski M et al: Improvement of respiratory compromise through abductor reinnervation and pacing in a patient with bilateral vocal fold impairment. Laryn­goscope 120:76, 2009; Chadha NK et al: Adjuvant antiviral therapy for recurrent respiratory papillomatosis. Cochrane Database Syst Rev Jan 20, 2010. Review; Hartl DM et al: Long-term acoustic comparison of thyroplasty versus autologous fat injection. Ann Otol Rhinol Laryngol 118:827, 2009; King EF et al: Vocal cord paralysis in children. Curr Opin Otolar­yngol Head Neck Surg 17:483, 2009; Kwak PE et al: Selective reinnervation of the posterior cricoarytenoid and interaryte­noid muscles: An anatomical study. Laryngoscope Jan, 11 2010. [Epub ahead of print]; McRae BR et al: Local neurotoxins for prevention of laryngeal synkinesis after recurrent laryngeal nerve injury. Ann Otol Rhinol Laryngol 118:887, 2009; Rosen CA et al: Vocal fold augmentation with calcium hydroxylapatite: twelve-month report. Laryngoscope 119:1033, 2009; Sulica L et al: Current practice in injection augmentation of the vocal folds: indications, treatment principles, tech­niques, and complications. Laryngoscope 120:319, 2010; Tateya I: Laryngeal steroid injection. Curr Opin Otolaryngol Head Neck Surg 17:424, 2009; Umeno H et al: Comparative study of framework surgery and fat injection laryngoplasty. J Laryngol Otol Suppl May:35, 2009.