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Systematic Review
INTRODUCTION
Unilateral vocal fold paralysis (UVFP) is a common
condition presenting to the otolaryngologisthead and
neck surgeon. The most common cause includes damage
to the recurrent laryngeal nerve (RLN) either iatrogenically or from a neoplasm. Patients with UVFP typically
present with voice changes, hoarseness, or aspiration.
Examination on laryngoscopy shows impaired vocal fold
motion, bowing of the fold, and incomplete glottic closure. Recovery from UVFP depends on the degree of
RLN damage, which can range from temporary neuropraxia to complete neural disruption. Some patients may
recover spontaneously over weeks to months with conservative management with voice therapy. However, fur-
RESULTS
A total of 504 studies were retrieved utilizing the
search strategy. Seventeen studies met all the inclusion
criteria. All studies were published between 1998 and
2014. Six studies made comparisons between injection
laryngoplasty and medialization thyroplasty (Table I).38
Six studies investigated arytenoid adduction alone or
with another procedure (Table II).6,913 Six studies had
laryngeal reinnervation as a main comparator of outcomes (Table III).1419 One study was a randomized controlled trial.16 Six studies were level 3 evidence, and 10
studies were level 4 evidence.
Four major categories of outcomes were found.
Acoustic and aerodynamic measures included acoustic
analysis for jitter, shimmer, harmonic-to-noise ratio,
maximum phonation time, glottic airflow, and subglottic
pressure. Subjective evaluation included perceptual evaluation and ratings on disability or quality of life. Perceptual scales used included the Grade, Roughness,
Breathiness, Asthenia, Strain scale and the Consensus
Auditory-Perceptual Evaluation of Voice, and selfreported instruments included the Voice Handicap Index
(VHI) and the Voice-Related Quality of Life scale. Laryngoscopic findings were utilized to characterize postoperative edema, degree of glottic closure, symmetry of
glottic closure, periodicity of glottic closure, and mucosal
wave. Last, other outcome measures included complication rates following each intervention.
DISCUSSION
Medialization Thyroplasty
Medialization thyroplasty, first described by Isshiki,
involves the creation of a window in the thyroid cartilage
and insertion of a permanent alloplastic implant to medialize the vocal fold.20 It has been considered the gold
standard approach to treatment of UVFP, and its benefiLaryngoscope 00: Month 2015
Injection Laryngoplasty
Medialization of a unilateral paralyzed vocal fold
can be achieved by injection of filler material into the
paraglottic space. Br
unings was the first to describe
injection laryngoplasty in 1911 using paraffin.23 Since
then, the technique has been refined, and a variety of
injected materials have been used including autologous
fat, calcium hydroxylapatite microspheres, bovine collagen, and methylcellulose.21 Seven of the 17 articles
reviewed discussed injection laryngoplasty as a comparator to other techniques (Table I).
Injection laryngoplasty and objective voice outcomes. Five articles focused on acoustics and aerodynamics as primary outcome measures.36,9 All studies
showed improvements in postoperative voice outcomes
regardless of intervention type. Two studies found no difference in postoperative outcomes between injection laryngoplasty and medialization thyroplasty.6,9 However,
the effect of injection laryngoplasty was not permanent
with 10 of 16 subjects, requiring multiple injections in
one study.6 Three studies found improved outcomes with
injection laryngoplasty. Cantillo-Ba~
nos et al. found that
harmonic-to-noise ratio was significantly improved in
the injection laryngoplasty group at 24 months compared to the medialization thyroplasty group.3 Two studies by Umeno et al. showed significantly greater
improvement in maximum phonation time, mean frequency range, and acoustic variables in the injection laryngoplasty group compared to medialization thyroplasty
alone or in combination with arytenoid adduction.4,5
These results were attributed to heterogeneity between
the groups prior to surgical intervention, as there was a
higher degree of premorbid respiratory disability (e.g.,
UVPF due to lung resection) and a greater vertical glottis height difference in the laryngeal framework group
compared to the injection laryngoplasty group.
Injection laryngoplasty and subjective voice
outcomes. All three studies that focused on subjective
voice outcomes as a primary outcome show postoperative
improvement in subjective voice outcomes.3,7,8 CantilloBa~
nos et al. found that aside from higher postoperative
VHI scores in medialization thyroplasty compared to
injection laryngoplasty, there were no differences in subjective voice outcomes including jitter, shimmer, and
Siu et al.: Comparison of Interventions for UVFP
LoE
Comparison
Andrews et al.6
Mortensen et al.9
Umeno et al.5
Vinson et al.8
Vinson et al.8
IL vs. MT
IL vs. MT
IL vs. MT
IL vs. MT
IL vs. MT
IL vs. LF
(AA/MT/MT 1 AA)
IL vs. MT vs.
(AA 1 MT)
IL vs. MT
IL vs. MT
Glottic closure,
symmetry,amplitude,
periodicity
Symmetry, amplitude,
periodicity,closure
patterns, glottic
closure
CAPE-V, VHI
CAPE-V, VHI
VHI
MPT, MFR
MPT
Outcome Measure
124 months
19 months
124 months
19 months
6 and 24 months
12 months 3 years
3 months
817 months
12 months4 years
6 and 24 months
Follow-up
In all outcome
measures
In all outcome
measures
Stats not
available
In all outcome
measures, but
not significantly
different
In all outcome
measures
In all outcome
measures
In all outcome
measures
In all outcome
measures
In all outcome
measures
IL had no
improvement
in shimmer
Postoperative
Improvement?*
No difference
No difference
No difference
No difference
No difference
No difference
Comparison of Interventions
Conclusions/Additional
Information
Morgan et al.7
Laryngoscopic outcomes
Morgan et al.7
Umeno et al.4
Article
TABLE I.
Outcome Measures Comparing Injection Laryngoplasty With Other Interventions.
LoE
Comparison
Sonoda et al.11
Murata et al.10
(AA 1 MT)vs. IL
(AA/lateral traction)
vs. (AA 1 MT)
Complication rates
Complication rates
Glottic gap
Glottic gap
GRBAS
MPT
Outcome Measure
6 months1 year
NA
NA
9 weeks
817 months
NA
6 months1 year
3 months
Follow-up
NA
NA
NA
NA
In all outcome
measures
In all outcome
measures
In all outcome
measures
In all outcome
measures
Postoperative
Improvement
No difference
No difference
No difference
Significant improvement
in degree of change of
acoustic and aerodynamic
parameters for AA 1 MT
No difference
Comparison of Interventions
No difference in improvement of
outcomes between groups
No difference in improvement of
outcomes between groups
No difference in improvement of
outcomes between groups
Conclusions
AA 5 arytenoid adduction; eAA 5 endoscopic arytenoid adduction; GRBAS 5 Grade, Roughness, Breathiness, Asthenia, Strain; HNR 5 harmonic to noise ratio; IL 5 injection laryngoplasty; LoE 5 level
of evidence; MFR 5 mean airflow rate; MPT 5 mean phonation time; MT 5 medialization thyroplasty; NA 5 not available; UVFP 5 unilateral vocal fold paralysis.
Abraham et al.13
Complications
Abraham et al.13
Li et al.12
Laryngoscopic outcomes
Murata et al.10
Article
TABLE II.
Outcome Measures Comparing Arytenoid Adduction With Other Interventions.
LoE
Comparison
Hassan et al.15
Paniello et al.16
Havas and
Priestley17
Tucker18
Paniello et al.16
LR vs. IL vs. MT
GRBAS, VRQOL
MPT, CPP
Jitter, shimmer,
HNR, MPT
Outcome Measure
Postoperative
day 3
NA
12 months
6 months
and 2 years
2 months8 years
3, 12, and
24 months
6, 12 months
3, 12, 24 months
NA
Follow-up
Postoperative
improvement
In all outcome
measures
In all outcome
measures
Stats not
available
Stats not
available
In all outcome
measures
In all outcome
measures
In all outcome
measures
In all outcome
measures
Postoperative
Improvement
No difference
No difference
No difference
No difference
Comparison of
Interventions
Conclusions
AA 5 arytenoid adduction; CPP 5 cepstral peak prominence; GRBAS 5 Grade, Roughness, Breathiness, Asthenia, Strain; HNR 5 harmonics to noise ratio; IL 5 injection laryngoplasty; LoE 5 level of evidence; LR 5 laryngeal reinnervation; MPT 5 maximum phonation time; MT 5 medialization thyroplasty; NA 5 not available; NMP 5 neuromuscular pedicle; NS 5 not significant; UVFP 5 unilateral vocal fold
paralysis; VRQOL 5 voice-related quality of life.
Narajos et al.19
Laryngoscopic outcomes
Chhetri et al.14
3
Hassan et al.15
Chhetri et al.14
Article
TABLE III.
Outcome Measures Comparing Laryngeal Reinnervation With Other Interventions.
harmonic-to-noise parameters between these two interventions.3 Similarly, two other studies reported no difference in subjective voice outcome parameters when
injection laryngoplasty was compared to medialization
thyroplasty.7,8
Laryngoscopy. The two studies that used glottic
closure, symmetry, and amplitude periodicity on laryngoscopic examination as primary outcome measures both
showed no difference in outcomes between injection laryngoplasty and medialization thyroplasty.7,8
Arytenoid Adduction
First described by Isshiki et al. in 1978, arytenoid
adduction involves medialization of the posterior vocal
fold by placement of a suture in the muscular portion of
the arytenoid, thereby simulating contraction of the lateral cricoarytenoid muscle.24 Theoretically, this results
in an improvement in posterior glottic gap closure.
Although arytenoid adduction offers several advantages
over other procedures, it is a technically challenging procedure that involves significant laryngeal manipulation
of the cricoarytenoid joint. Compared to medialization
thyroplasty, it is associated with an increase in overall
complications including airway obstruction due to laryngeal edema, dysphagia, and increased operating time.13
Addition of arytenoid adduction to medialization thyroplasty or injection laryngoplasty. Arytenoid adduction is often performed in combination with
medialization thyroplasty or injection laryngoplasty.
Andrews et al. found no difference between subjective
voice outcomes between arytenoid adduction with medialization thyroplasty compared to injection laryngoplasty. Mortensen et al. found that there was an added
benefit of arytenoid adduction to acoustic or aerodynamic outcome measures including jitter, shimmer,
harmonic-to-noise ratio, mean phonation time, mean
phonatory flow, or subglottic pressure, but this did not
reach statistical significance. Multivariate analysis
showed a statistically greater degree of change of acoustic and aerodynamic parameters in this group.9
Two studies investigated laryngoscopic outcomes.
Abraham et al. conducted the largest study with 194
patients: 98 underwent medialization thyroplasty alone
compared with 96 who underwent medialization thyroplasty combined with arytenoid adduction. In this study,
the addition of arytenoid adduction to medialization thyroplasty resulted in significantly improved closure of the
posterior glottis on laryngoscopy, with no statistical difference in complication rates.13 This improvement in
glottic closure was not reproducible in a study by Li
et al. However, this was a much smaller-scale study
involving 10 patients who had medialization thyroplasty
and arytenoid adduction compared to 35 patients who
had medialization thyroplasty alone.12 Differences in
results between these two studies may also be due to
variability between groups in terms of preoperative
comorbidities, glottic closure patterns, and vertical
height discrepancies.
Laryngoscope 00: Month 2015
Arytenoid adduction and technique modifications. To address the increased complication rates associated with the increased technical difficulty of
arytenoid adduction, two studies introduced modified
arytenoid adduction methods in attempt to reduce complication rates.10,11 Murata et al. found that endoscopicassisted arytenoid adduction surgery yielded similar
postoperative acoustic and aerodynamic results, with no
significant added complication rates when performed
alone and in combination with medialization thyroplasty
or injection laryngoplasty.10 Sonoda et al. introduced a
modified open arytenoid adduction technique to avoid
dissection of the posterior edge of the thyroid cartilage
and damage to the surrounding tissues. Lateral traction
is applied to the cricoarytenoid muscle using nylon
sutures pulled anterocaudally.11 This modified open technique was found to have similar results as compared to
arytenoid adduction and medialization thyroplasty in
achieving successful voice outcomes as measured by
maximum phonation time of more than 10 seconds.
Arytenoid adduction summary. Arytenoid adduction can be performed either alone or in combination
with other techniques. The hypothesis that this technique results in an improvement in posterior glottic gap
was demonstrated in one study, but not in another.12,13
Mortensen et al. also demonstrated no statistically significant added benefit of arytenoid adduction to medialization thyroplasty on acoustic and aerodynamic voice
outcomes.9 Modified arytenoid adduction techniques
have been developed to improve complication rates associated with the traditional approach. Further research is
necessary to improve comparisons between approaches.
Laryngeal Reinnervation
Laryngeal reinnervation was introduced as a technique to prevent long-term atrophy and decreased stiffness of a paralyzed vocal fold, which can occur with
medialization thyroplasty. Vocal fold bulk, stiffness, and
tension are maintained by providing nerve supply to the
thyroarytenoid adductor muscles. It is the resultant
medialization of the vocal fold, rather than complete restoration of dynamic vocal fold movement, that leads to
voice improvements with this technique. Functional restoration of the vocal fold is limited by disorganized axon
regrowth, resulting in synkinesis.
There are a variety of approaches to reinnervation
including primary anastomosis of the transected recurrent laryngeal, nerve-muscle pedicle transfer to the thyroarytenoid muscle, direct ansa cervicalis nerve
implantation onto the thyroarytenoid muscle, and anastomosis between a donor nerve (usually the hypoglossal,
phrenic, or ansa cervicalis) and the recurrent laryngeal
nerve.25
Laryngeal reinnervation alone. Paniello et al.
conducted the most robust study directly comparing
laryngeal reinnervation with medialization thyroplasty
in a multicenter randomized control trial with 12 subjects in each arm.16 Results from the study suggest a
delayed onset of improved outcomes with reinnervation.
Minimal differences in auditory and perceptual voice
Siu et al.: Comparison of Interventions for UVFP
Overall Observations
A wide variety of effective procedural interventions
are available for patients with UVFP. Each of these techniques may be performed in isolation or in combination
with other techniques. Each technique has relative
strengths and weaknesses. Patient selection, etiology of
the paralysis, and preoperative laryngoscopic findings
are all necessary considerations when considering an
optimal, individualized approach. Table IV summarizes
the overall observations of each technique according the
findings of this study.
Limitations
A wide breadth of literature has been published on
the topic of UVFP. This study was conducted in an
attempt to systematically review all head-to-head comparisons between interventions. This study, as a systemic review, is limited by the quality of the included
studies. Because it is a collection of findings from various other studies, it provides an overview of the direction of the literature, but is unable to show new
findings. This study is not a meta-analysis, and study
results have not been statistically combined for more
powerful results. As well, only English-language studies
were able to be included in this review.
Interpretation of the pooled dataset was particularly challenging due to a variety of factors. First, there
is significant variation across the studies in methodology
and study design. Lack of standardization in outcome
measures and differences in reporting outcome data
make generalizability between studies difficult. Furthermore, there was significant heterogeneity in preoperative patient population, length of postprocedural followup, and breadth of surgical combinations. All of these
factors could contribute to why there were no differences
seen in the outcome measures across interventions. Second, differences in surgical technique and preferred
materials are vast between institutions and surgeons.
Within each surgical technique, there is significant variability in the amount of material injected, durability of
the injected material, and type of injection or implant.
All of these factors make comparisons of the results
between institutions additionally challenging. Finally, as
with any comparison of surgical technique, surgeon
Siu et al.: Comparison of Interventions for UVFP
TABLE IV.
Summary of Interventions by Strengths and Weaknesses.
Technique
Strengths
Weakness
Medialization thyroplasty
Immediate result
Injection laryngoplasty
Simple procedure
Can be completed in a clinic setting
Laryngeal reinnervation
Technically challenging
More manipulation of the larynx resulting in more
complications compared to medialization thyroplasty
Requires operating room time
Technically challenging
No immediate result when done alone
Requires operating room time
FUTURE DIRECTIONS
Overall, standardized study protocols outlining outcome measures, method of reporting measurements, and
follow-up intervals would facilitate future analysis of
data, including meta-analyses. In this review, only one
study attempted to investigate aspiration outcomes in a
systematic way. As aspiration is a major complication of
UVFP, further studies objectively investigating this outcome measure may direct decisions for intervention in
this subset of patients.
CONCLUSION
Based on this review, there is no definitive evidence
suggesting superiority of any one technique on acoustic
and aerodynamic parameters, perceptual voice outcomes,
and laryngoscopic findings. Current evidence suggests
that although voice outcomes are similar between medialization thyroplasty and injection laryngoplasty initially
following the procedures, long-term results may favor
the former. Furthermore, injection laryngoplasty may be
favored in patients who are unable to tolerate general
anesthetic and those who wish to have a more immediate short-term benefit. Laryngeal reinnervation techniques may be best used in combination with other
laryngeal framework techniques for longer-term benefit
and may be best reserved for younger patients. All procedures were shown to be safe, and not associated with
any significant perioperative morbidity.
Overall, a variety of procedures are available within
the otolaryngologists armamentarium for treating
Laryngoscope 00: Month 2015
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