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Data and Picture Interpretation Stations: Cases 1–45
Published in Peter Kullar, Joseph Manjaly, Livy Kenyon, Joseph Manjaly, Peter Kullar, Joseph Manjaly, Peter Kullar, ENT OSCEs, 2023
Peter Kullar, Joseph Manjaly, Livy Kenyon, Joseph Manjaly, Peter Kullar, Joseph Manjaly, Peter Kullar
Unilateral vocal cord paralysis presents with dysphonia (often breathy voice), dysphagia and shortness of breath. It can result from direct trauma to vocal cord (such as intubation) or secondary to damage to the recurrent laryngeal nerve e.g. by cancer, trauma or surgery. The recurrent laryngeal nerve arises from vagus nerve and courses from the brainstem through the neck and chest. Diagnosis is usually made with clinic based flexible nasendoscopy. A CT scan from the skull base to diaphragm covers the entire length of the recurrent laryngeal nerve and is an important investigation in establishing a diagnosis. Speech and language therapy can improve voice projection and pitch control. Voice quality can also be improved by surgical medialisation procedures including vocal cord injections, thyroplasty and in some instances laryngeal reinnervation procedures.
The spectrum of voice disorders – classification
Published in Stephanie Martin, Working with Voice Disorders, 2020
While voice training procedures are one route for the MtF TGNC patient, surgical intervention is another. Laryngeal surgery may be effective to help to raise vocal pitch, but as with any surgery the procedure is not without risk. A three-year follow-up study of a Type IV thyroplasty (Gibbons et al., 2011) reported findings of increased pitch definition and clarity but decreased range overall. Surgery, however, will not always be available to patients, and clinicians may have MtF transition patients referred who have not had, and will not have, surgery.
Phonosurgery
Published in John C Watkinson, Raymond W Clarke, Terry M Jones, Vinidh Paleri, Nicholas White, Tim Woolford, Head & Neck Surgery Plastic Surgery, 2018
Type I, or medialization thyroplasty, can be performed for patients with a unilateral vocal cord paralysis. Waiting 12 months in idiopathic cases is recommended for possible spontaneous recovery of vocal fold motion. Injection laryngoplasty should be provided within this initial time period to allow for adequate voicing and cough. Medialization thyroplasty can also performed bilaterally in cases of bilateral bowed vocal cords, as can be caused by ageing, and may be useful to correct soft tissue defects in the vocal fold as a result of previous surgery, although the final voice expectations for these diagnoses should be quite guarded.
Diagnostic vocal fold injection as an intervention for secondary muscle tension dysphonia
Published in Hearing, Balance and Communication, 2021
Christopher D. Dwyer, Thomas L. Carroll
The ideal augmentative procedure or injectable of choice remains unknown. There is a paucity of randomised trials demonstrating procedure superiority. The choice of durable augmentation procedure is largely driven by patient preference. Thyroplasty offers the advantage of customised and precise contouring/medialization of the vocal fold based on implant positioning, no need for overcorrection, and implants are permanent. Though they are a foreign body with risk of infection, migration and extrusion. Autologous fat is advantageous given it is poses minimal immune reaction risk and is performed endoscopically avoiding a neck scar. Fat also has the potential to be a permanent implant, however, resorption rates are variable and necessitates overcorrection at the time of injection. Calcium hydroxylapatite is an appealing, widely used material as it can be easily injected as an awake procedure, but is limited in its durability (upwards to 18 months) [35]. Silk-hyaluronic acid is a new injectable, potentially permanent in duration, that is currently being trialled by the senior author with good success anecdotally.
Walking the thin white line – managing voice in the older adult
Published in Speech, Language and Hearing, 2019
External procedures are often undertaken using local anaesthetic and sedation to enable the surgeon to titrate the amount of implant to the vocal quality, by having the patient phonate whilst in the operating room (Johns et al., 2011; Zeitels, Mauri, & Dailey, 2003). Sachs et al evaluated 22 patients undergoing either bilateral thyroplasty or injection augmentation for age-related atrophy of the vocal folds. Self-reported voice-related quality of life (VR-QOL) scores improved in thyroplasty patients but not in those undergoing injection laryngoplasty (Sachs, Bielamowicz, & Stager, 2017). In fact, patients post-injection did not report any benefit of injection laryngoplasty and mean VR-QOL scores decreased (worsened) by an average of 16 points (Sachs et al., 2017). Given that Gore-tex implant is designed to be permanent, there are risks of mal-positioning requiring revision surgery, and implant infection or extrusion (also requiring removal of the implant). This leaves an ‘empty glottis’ and potential for scar contraction of the previously elevated pocket, which can be difficult to subsequently correct (Conoyer, Netterville, Chen, & Vos, 2006).
Efficacy of speech language therapy intervention in unilateral vocal fold paralysis – a systematic review and a meta-analysis of visual-perceptual outcome measures
Published in Logopedics Phoniatrics Vocology, 2021
Rita Alegria, Susana Vaz Freitas, Maria Conceição Manso
Siu et al. [13] reported the voice outcomes after interventions for UVFP and showed that injection laryngoplasty (IL) improved the acoustic and aerodynamic voice outcomes in almost all measures of the reviewed studies. Furthermore, voice improvement was sustained for as long as 4 years and comparable results were obtained when a medialization thyroplasty (MT) was performed. The timing of the intervention seems to significantly affect the effect size of the intervention in patients with UVFP after thyroidectomy, according to Chen et al. [12]. The authors recommend that reversible interventions, such as IL and MT, be performed within the first 12 months of the onset of paralysis to augment the natural healing process.