Original Research
Otolaryngology
Voice Outcomes following a Single Office-
Based Steroid Injection for Vocal Fold
Scar
William G. Young, MD1,2, Matthew R. Hoffman, MD, PhD2,
Ian J. Koszewski, MD2, Chad W. Whited, MD2,3,
Brienne N. Ruel, MA, CCC-SLP2, and Seth H. Dailey, MD2
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. Persistent dysphonia from vocal fold scar remains
a clinical challenge, with current therapies providing incon-
sistent outcomes. We evaluated voice outcomes after a
single office-based steroid injection.
Study Design. Case series with chart review.
Setting. Academic medical center.
Subjects and Methods. This study was based on pre- and post-
operative analysis of patient-reported, perceptual, acoustic,
aerodynamic, and videostroboscopic parameters. The sample
comprised 25 patients undergoing office-based dexametha-
sone injection into the superficial lamina propria for mild/
moderate vocal fold scar. Average follow-up was 13.7 6 4.4
weeks; patients completed 3.5 6 2.3 sessions of voice ther-
apy between assessments. Complete data sets were not avail-
able for each parameter; sample size is noted with results.
Results. Voice handicap index (n = 24; P \ .001) and glottal
function index (n = 22; P \ .001) decreased after injection.
Total GRBAS score (grade, roughness, breathiness, asthenia,
strain) decreased (n = 25; P \ .001). Fundamental frequency
range increased (n = 24; P = .024). Phonation threshold pres-
sure decreased (n = 14; P = .017). Videostroboscopic para-
meters of vocal fold edge (P = .004), glottic closure (P = .003),
and right mucosal wave (P = .016) improved after injection.
Conclusions. Office-based steroid injection combined with
voice therapy for mild/moderate vocal fold scar is associated
with improved patient-reported and functional voice mea-
sures. These findings provide preliminary support for this
approach. Importantly, the procedure is low risk and can be
performed in the office, thus offering a simple treatment
alternative to patients with a disorder that has traditionally
been difficult to manage. Prospective studies evaluating the
effects of multiple injections are warranted.
Keywords
vocal fold scar, steroid injection, dysphonia, vocal fold
injection
Downloaded from oto.sagepub.com at CORNELL UNIV WEILL MED COLG on August 17, 2016
Head and Neck Surgery
19
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2016
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599816654899
http://otojournal.org
Received October 8, 2015; revised April 11, 2016; accepted May 25,
2016.
V
ocal fold scar is a natural consequence of vocal fold
injury, which can occur due to traumatic, inflamma-
tory, neoplastic, and iatrogenic causes.1 With scar,
the normal vocal fold volume and layered architecture2 are
lost. Reduced pliability and volume loss result in glottic
insufficiency and inefficient transduction of aerodynamic
into acoustic energy.1 The clinical challenge of treating
vocal fold scar remains daunting. Patients with scar are rele-
gated to invasive procedures, often with prolonged recovery
times and unpredictable results.
In general, healing after injury proceeds through inflam-
matory, proliferative, and remodeling phases, which overlap
in time.3 Inflammation includes the influx of neutrophils,
which act to eliminate potential pathogens.4 Proliferation is
characterized by angiogenesis, fibroblast migration, epithe-
lialization, and wound retraction.5 Fibroblasts synthesize
collagen, which provides strength to the healing wound, but
overproduction can result in hypertrophic scar.5 Remodeling
can last over a year and includes wound matrix breakdown
and synthesis of new extracellular matrix; imbalances in
matrix degradation and synthesis can result in abnormal scar
formation.6
1
Proliance Eastside Ear Nose and Throat, Kirkland, Washington, USA
2
Division of OtolaryngologyHead and Neck Surgery, Department of
Surgery, School of Medicine and Public Health, University of Wisconsin,
Madison, Wisconsin, USA
3
Austin Ear, Nose & Throat Clinic, Austin, Texas, USA
This article was presented as a poster at the American Laryngological
Association Annual Meeting (Boston, Massachusetts; April 22-23, 2015) and
as an oral presentation at the Wisconsin Society of Otolaryngology Annual
Meeting (Wisconsin Dells, Wisconsin; October 24-25, 2015).
Corresponding Author:
Seth H. Dailey, MD, Department of Surgery, Division of Otolaryngology
Head and Neck Surgery, University of Wisconsin School of Medicine and
Public Health, 600 Highland Ave, Clinical Science Center K4/760, Madison,
WI 53792, USA.
Email: dailey@surgery.wisc.edu
2 OtolaryngologyHead and Neck Surgery
Key aspects of wound healing specific to the vocal fold
include unregulated collagen synthesis after injury, resulting
in disorganized deposition of collagen fibers throughout the
lamina propria and decreased elastin; these factors increase
tissue viscosity and can lead to scar.7
Steroid injection has been effectively used to treat hyper-
trophic cutaneous scar and keloids,8 with therapeutic
mechanisms including anti-inflammatory effects as well as
the ability to decrease collagen synthesis, gyclosaminogly-
can synthesis, and fibroblast proliferation.9,10 This approach
has also been used in the vocal fold to treat nodules and
scar.11-13 Mortensen and Woo reported on stroboscopic and
perceptual analysis outcomes for 34 patients undergoing
office-based steroid injection, including 12 patients with
scar.13 Improved stroboscopic examination was observed in
11 of the 12 patients. Significant improvements in the per-
ceptual and stroboscopic parameters were reported for the
entire group of 34 patients as a whole, but disorder-specific
analyses were not performed.
We performed a retrospective series evaluating changes
in patient-reported, perceptual, acoustic, aerodynamic, and
videostroboscopic parameters following management of
vocal fold scar through office-based steroid injection. The
majority of patients also underwent voice therapy, but no
additional surgical procedures were performed. This repre-
sents the first study reporting comprehensive voice out-
comes following office-based steroid injection for scar.
Materials and Methods
This retrospective case series was approved by the
University of Wisconsin Health Sciences Institutional
Review Board. Subjects were identified with codes from the
International Classification of Diseases, Ninth Revision
(478.7, 478.70, 784.42, 784.4, 784.40, 784.41, or 784.49)
and Current Procedural Terminology (31513, 31570, 31571,
and 31599). Medical records of patients undergoing treat-
ment for vocal fold scar between 2006 and 2015 were
reviewed. Patients with mild to moderate vocal fold scar
who underwent office-based steroid injection and had pre-
and posttreatment voice assessments were selected. For this
study, mild to moderate scar was defined as scar affecting
vibration and/or glottal closure but not significant enough to
result in no visible vibration of any segment along the
affected vocal fold.
Patients
Twenty-five patients (12 males, 13 females) aged 53.3 6
14.7 years were included (Table 1). Average time between
pretreatment voice assessment and treatment was 6.8 6 3.8
weeks. Average time between treatment and posttreatment
voice assessment was 13.7 6 4.4 weeks.
Patients completed an average of 3.5 6 2.3 sessions of
voice therapy between the pre- and posttreatment voice assess-
ments (Table 2). This typically included resonant voice ther-
apy, although the specific approach for each patient is listed in
Table 2. Of 25 patients, 23 participated in voice therapy
between pre- and postoperative assessments.
Downloaded from oto.sagepub.com at CORNELL UNIV WEILL MED COLG on August 17, 2016
A majority of patients were taking antireflux medication
at the time of treatment. Two patients were on immunosup-
pressive therapy for treatment of autoimmune disease, and 2
patients were on corticosteroid therapy at the time of treat-
ment. Relevant medications for each patient are listed in
Table 1.
Injection Procedure
Dexamethasone sodium phosphate (10 mg/mL; APP
Pharmaceuticals, Inc, Schaumburg, Illinois) is injected
directly into the superficial lamina propria of the scarred
vocal fold (Figures 1 and 2). The injection is performed
while awake with only topical anesthesia and a transoral or
transnasal approach. For the transoral approach, 4% lidocaine
is applied via mucosal atomization to the oropharynx and
then via Abraham cannula to the larynx. A 70-degree tele-
scope (model 9108; Kaypentax, Montvale, New Jersey) is
used to visualize the larynx, while a Xomed orotracheal
injector curved cannula and disposable needle (models
650025 and 1650050; Medtronic Xomed Surgical Products,
Inc, Jacksonville, Florida) are used to inject the dexametha-
sone into the superficial lamina propria. For the transnasal
approach, the nose is anesthetized and decongested with 4%
lidocaine and 0.05% oxymetazoline. A distal chip flexible
laryngoscope with a working channel (model ENF-VT2;
Olympus America, Center Valley, Pennsylvania) is advanced
to the level of the larynx, and 4% lidocaine is applied during
sustained phonation. Once the larynx is anesthetized, a scler-
otherapy needle (model NM-201L-0425; Olympus America)
is passed through the working channel, and the dexametha-
sone is injected into the superficial lamina propria. Patients
are counseled to avoid talking for 3 days after the procedure,
as voice abuse in the postoperative period is associated with
prolonged postoperative dysphonia.14,15 Compliance with this
recommendation was not assessed.
Outcome Measures
Pre- and postoperative patient-reported, perceptual, acoustic,
aerodynamic, and videostroboscopic parameters were
recorded from medical records. Measurements were
recorded as part of a standard voice assessment performed
by a speech-language pathologist.
Patient-reported voice changes were assessed with the
Voice Handicap Index,16 glottal function index,17 and Iowa
Patients Voice Index.18 Overall score and individual scores
on the subcategories of the Voice Handicap Index (func-
tional, physical, and emotional) were evaluated. Patients
also completed a reflux symptom index questionnaire.19
Perceptual analysis was performed with the GRBAS
rating scale (grade, roughness, breathiness, asthenia, strain).20
Acoustic measures included minimum and maximum funda-
mental frequency, phonatory frequency range, minimum inten-
sity, percentage jitter, and the dysphonia severity index (DSI).21
Signals were recorded through the Computerized Speech Lab
(model 4150B; KayPENTAX) and Multi-dimensional Voice
Program (model 5105; KayPENTAX). To measure minimum
and maximum fundamental frequency, patients performed 3
Young et al 3

Table 1. Demographic Information.a

Patient Age, y Sex Etiology/Contributing Factors Other Relevant Medications

1 41 M Tobacco use, minimal GERD None

2 47 F Bilateral polyp excision, GERD Dexlansoprazole
3 68 F Sinusitis, GERD Omeprazole, ranitidine
4 52 F CREST, GERD Esomeprazole, mycophenolate mofetil
5 46 F Preceding URI Omeprazole
6 42 F High vocal load None
7 50 M GERD Omeprazole, ranitidine
8 65 M Presbyphonia Omeprazole
9 35 M High vocal load None
10 80 M Tobacco use, high vocal load, presbyphonia Omeprazole
11 43 F High vocal load None
12 58 M High vocal load None
13 61 F GERD, chronic cough Rabeprazole, ranitidine
14 65 M High vocal load, chronic cough Omeprazole
15 83 F Preceding bronchitis Pantoprazole, famotidine
16 48 M High vocal load, GERD Omeprazole
17 62 F Traumatic intubation, rheumatoid arthritis Adalimumab, meloxicam, abatacept, hydroxycholorquine,
methotrexate, prednisone, omeprazole
18 52 M Chronic cough Prednisone, omeprazole
19 33 M Polyp excision None
20 36 F Rheumatoid arthritis Adalimumab, etanercept, etodolac, methotrexate, omeprazole
21 53 F GERD Omeprazole, ranitidine
22 39 M High vocal load Omeprazole
23 79 M Prolonged intubation Prednisone
24 32 F High vocal load None
25 62 F Idiopathic, worsening after recent URI Omeprazole, randitidine
Abbreviations: CREST, calcinosis cutis, Raynauds phenomenon, esophageal dysmotility, sclerodactyly, telangiectasias; F, female; GERD, gastroesophageal reflux
disease; M, male; URI, upper respiratory infection.
a
High vocal load refers to heavy occupational or recreational voice use.

trials, each consisting of ascending and descending glissandos
on the vowel /a/, trying to reach the lowest and highest frequen-
cies possible. For percentage jitter, patients produced a stable /
a/ at comfortable pitch and loudness.
Aerodynamic measurements included maximum phonation
time (MPT), phonation threshold pressure (PTP), mean flow
rate (MFR), subglottal pressure, and laryngeal resistance.
Measurements were obtained with the Phonatory Aerodynamic
System (model 6600; KayPENTAX). For MPT, patients per-
formed 3 trials, each consisting of phonation of a sustained /a/
at modal pitch for as long as possible; the longest trial was
recorded as the MPT. For MFR, subglottal pressure, and laryn-
geal resistance, patients produced 3 /pa/ syllable trains at com-
fortable pitch and loudness; the first and last syllables were
removed and the average values for each parameter computed.
For PTP, patients produced 3 /pi/ syllable trains at the softest
possible volume; the lowest subglottal pressure at which pho-
nation occurred was recorded as the PTP.
Videostroboscopy was completed with a Kay Elemetrics
RLS 9100B system (Kay Elemetrics, Lincoln Park, New
Jersey) attached to a 70-degree rigid endoscope or a flexible
distal chip rhinolaryngoscope. The following variables were
Downloaded from oto.sagepub.com at CORNELL UNIV WEILL MED COLG on August 17, 2016
assessed: vocal fold edge contour (straight, convex, concave,
or irregular), glottic closure (complete, anterior and/or poster-
ior gap, or spindle), vibratory amplitude (normal, reduced, or
absent), and mucosal wave (normal or reduced). Vibratory
amplitude refers to horizontal movement of the vocal fold
body, while mucosal wave refers to horizontal and vertical
movement of the vocal fold cover. Archived stroboscopic
videos were reanalyzed by a single speech-language patholo-
gist (B.N.R.). Complete sets were not archived for 4 patients;
analysis is included for 19 patients. Detailed stroboscopic
analysis can be subjective and dependent on frequency and
amplitude, which were not standardized in this retrospective
study. While subtle increases in mucosal wave or vibratory
amplitude may be due to changes in patient effort, amplitude,
or frequency, significant improvements or transitions to
normal represent clinically meaningful change. Thus, a sim-
plistic approach was used for analysis, with parameters rated
as normal or abnormal preinjection and normal,ab-
normal, or improved postinjection. Improved indicates
a move toward normal without reaching normal.
A protocol is in place at our institution for collection of
voice measures at clinical visits; however, occasionally, not
4 OtolaryngologyHead and Neck Surgery

Table 2. Patient Treatment Information.

Patient Scar Position Procedure Voice Therapy

1 Bilateral Bilateral steroid injection Resonance, straw phonation, voice building

2 Bilateral, left . right Bilateral steroid injection Resonance
3 Left Left steroid injection Resonance
4 Right Right steroid injection Resonance
5 Bilateral, left . right Bilateral steroid injection Resonance, lip/tongue trill
6 Bilateral Bilateral steroid injection Resonance, lip trills
7 Bilateral Bilateral steroid injection Resonance, Z and Y buzz
8 Bilateral Bilateral steroid injection Modified resonance, straw phonation
9 Bilateral Bilateral steroid injection Resonance, flow mode, tongue trills, functional phrases
10 Bilateral Bilateral steroid injection Resonance
11 Bilateral Bilateral steroid injection Resonance, lip trills, reading tasks
12 Bilateral Bilateral steroid injection Resonance, abdominal breathing, tongue trills, laryngeal massage
13 Bilateral Bilateral steroid injection Resonance, lip trills
14 Bilateral, left . right Bilateral steroid injection Resonance, vocal hygiene, breath support, therapeutic
massage, strengthening / coordination exercises
15 Bilateral Bilateral steroid injection Semi-occluded vocal tract, lip trills
16 Left Left steroid injection Nonea
17 Left Left steroid injection Resonance, semioccluded vocal tract, airflow balance
18 Bilateral Bilateral steroid injection Resonance, lip trills
19 Right Right steroid injection Resonance, laryngeal massage, straw phonation
20 Bilateral Bilateral steroid injection Resonance, lip trills, laryngeal massage, pitch glides
21 Bilateral Bilateral steroid injection Z and Y buzz, resonance
22 Bilateral Bilateral steroid injection None
23 Bilateral Bilateral steroid injection Buzzy /u/, functional phrases
24 Bilateral Bilateral steroid injection Resonance, tongue trills, vocal hygiene, vocal function exercises
25 Bilateral Bilateral steroid injection Resonance, vocal hygiene, lip trills, cup bubble
a
Patient 16 had no sessions between data collection points but had 5 sessions in the 4 months prior to preinjection data collection, including straw phona-
tion, resonance, and humming.

number of patients included in each analysis is specified. A

patient was not included in the analysis for a given parameter
if he or she did not have a measurement of that parameter
before and after steroid injection.

Figure 1. Transnasal steroid injection of left vocal fold with flexible
distal chip endoscope. Note clear edema of the injected vocal fold.
Statistical Analysis
Evaluation of treatment efficacy for patient-reported, per-
ceptual, acoustic, and aerodynamic parameters was per-
formed with paired t tests. If data did not meet assumptions
for parametric testing, a Wilcoxon-Mann-Whitney signed-
rank test was performed. Changes in videostroboscopic
parameters were evaluated with McNemars tests. Numbers
of patients with parameters rated as normal versus abnormal
preinjection were compared to those with normal 1
improved versus abnormal postinjection. All tests were 2-
tailed with a significance level of a = 0.05. As a complete
data set was not available for every patient, the number of
patients included in the analysis for each parameter is
reported with the corresponding result.

all measurements are performed at each visit. Thus, a complete Results

data set with all parameters was not available for every patient. Total Voice Handicap Index decreased significantly (P \
Analyses were performed according to available data, and the .001; Figure 3). Decreases in each component were also
Downloaded from oto.sagepub.com at CORNELL UNIV WEILL MED COLG on August 17, 2016
Young et al
Figure 2. Pre- and postinjection images from 1 patient. Before
injection (A), there was an irregular left vocal fold edge and hour-
glass glottic closure pattern, consistent with scar. After injection
(B), there was improved vocal fold contour and glottic closure.
observed (Table 3). Reflux symptom index (P \ .001) and
glottal function index decreased significantly (P  .001), as
did the voice quality (P = .031) and voice impairment (P =
.004) components of the Iowa Patients Voice Index.
Improvements in perceptual analysis were also observed
(Figure 4). Total GRBAS score decreased after injection (P \
.001), as did the grade (P \ .001), roughness (P \ .001),
breathiness (P = .002), and strain (P = .002) components.
Minimum fundamental frequency was unchanged after
injection, while maximum fundamental frequency (P =
.019) and frequency range (P = .024) increased. No changes
were observed in DSI or percentage jitter.
PTP decreased significantly after injection (P = .017;
Figure 5). MPT, subglottal pressure, MFR, and laryngeal
resistance did not change after injection.
Following steroid injection, patients tended to improve or
normalize for vocal fold edge (P = .004), glottic closure (P =
.003), and right mucosal wave (P = .016; Table 4). There
were not significant changes for the other videostroboscopic
parameters (Table 4).
Downloaded from oto.sagepub.com at CORNELL UNIV WEILL MED COLG on August 17, 2016
5
Figure 3. Voice Handicap Index scores before and after steroid
injection. Bars represent mean score, and error bars represent
standard error of the mean. All scores decreased significantly after
injection.
Discussion
There has been little published on the effects of steroid
injection for treatment of vocal fold scar in humans.22
Relevant studies include that by Mortensen and Woo,13 who
observed improvements in videostroboscopic and perceptual
analyses; a case report of 2 patients experiencing reversible
atrophy after serial steroid injections23; and 13 patients
within a larger series of 115 patients undergoing steroid
injection for a variety of benign lesions.24 Importantly, no
studies have performed a comprehensive voice assessment
on patients with only vocal fold scar before and after steroid
injection. We sought to address this gap, analyzing changes
in patient-reported, perceptual, acoustic, aerodynamic, and
videostroboscopic parameters.
Significant improvements in the patient-reported Voice
Handicap Index, glottal function index, and Iowa Patients
Voice Index are encouraging, as they represent an improve-
ment in patients quality of life after steroid injection.
Within the Voice Handicap Index, changes were most pro-
minent for the physical component. This may reflect more
efficient voice production, which corresponds to the
decreased PTP observed on aerodynamic assessment, as
well as improved voice consistency throughout the day.
Improved perceived voice quality and decreased voice
impairment were also apparent with the changes in the Iowa
Patients Voice Index.
Perceptual analysis is a critical component of voice
assessment.25 Decreases were observed in each component
of the GRBAS scale, reflecting decreased dysphonia sever-
ity and improved voice quality. Reviewing each component,
voice tended to change from mild-moderate dysphonia to
normal-mild dysphonia.
Changes in acoustic parameters were most prominent for
maximum fundamental frequency, which also led to an
increase in fundamental frequency range. Decreased phona-
tory frequency range is common with vocal fold scar.26
6 OtolaryngologyHead and Neck Surgery

Table 3. Data before and after Injection.a

Parameter Preinjection Postinjection n P Value

Patient reported
Voice Handicap Index
Functional 9.9 6 5.8 5.2 6 5.8 21 .012
Physical 15.8 6 8.9 9.2 6 8.0 21 .003
Emotional 7.4 6 5.8 4.0 6 4.7 21 .002
Total 38.3 6 21.7 23.3 6 22.2 24 \.001
Reflux symptom index 13.3 6 6.8 8.3 6 6.2 24 \.001
Glottal function index 9.9 6 4.8 5.0 6 5.3 22 \.001
Iowa Patients Voice Index
Quality 2.9 6 1.7 2.0 6 1.4 14 .031
Impairment 2.6 6 1.7 1.3 6 1.6 14 .004
Effort 182 6 86 149 6 54 14 .084
Perceptual
Grade 2.0 6 0.5 1.3 6 0.6 25 \.001
Roughness 1.5 6 0.8 0.9 6 0.5 25 \.001
Breathiness 1.3 6 0.9 0.7 6 0.9 25 .002
Asthenia 0.6 6 0.8 0.3 6 0.6 25 .055
Strain 1.1 6 1.0 0.5 6 0.8 25 .005
GRBAS total 6.5 6 2.5 3.7 6 1.9 25 \.001
Acoustic
Dysphonia severity index 1.6 6 4.4 0.8 6 3.5 22 .338
Jitter, % 2.40 6 1.98 2.17 6 2.15 24 .582
F0, Hz
Minimum 118 6 27 118 6 36 24 .808
Maximum 554 6 174 626 6 210 24 .019
Range 437 6 174 507 6 209 24 .024
Aerodynamic
MPT, s 15.5 6 9.7 13.8 6 6.6 25 .360
PTP, cmH2O 7.33 6 2.34 5.69 6 2.40 14 .017
Mean flow rate, L/s 0.33 6 0.18 0.27 6 0.12 12 .313
Subglottal pressure, cmH2O 11.25 6 3.29 10.25 6 2.96 13 .230
Laryngeal resistance, cmH2O/L/s 43.73 6 28.39 39.82 6 10.83 12 .664

Abbreviations: F0, fundamental frequency; GRBAS, grade, roughness, breathiness, asthenia, strain; L, left; MPT, maximum phonation time; PTP, phonation
threshold pressure; R, right.
a
Values reported as mean 6 SD.

Higher fundamental frequencies were achieved after injec-
tion, likely attributable to improved mucosal pliability.
Participation in voice therapy could also have contributed to
this change.1 The DSI is a derived measure that includes
MPT, maximum fundamental frequency, low intensity, and
percentage jitter.21 MPT and percentage jitter were
unchanged, but the change in maximum fundamental fre-
quency was significant, accounting for the move toward the
normal range of the DSI. Of note, intersubject variability
was fairly large, and there was no statistically significant
change.
Vocal fold scar can adversely affect voice production via
2 principal mechanisms: impairing glottic closure and
impairing vibration of the affected vocal fold segment.27
Insights by which steroid injection improves vocal fold
vibration can be gained by evaluating the aerodynamic and
videostroboscopic data. The largest improvement in aerody-
namic parameters occurred with PTP, with the observed
decrease likely due to decreased vocal fold stiffness, a key
determinant of the measure.28 This is also reflected in the
increased number of patients with normal or improved vocal
fold contour and mucosal wave on videostroboscopy. Less
notable changes were observed for MPT, MFR, and laryn-
geal resistance3 aerodynamic parameters sensitive to glot-
tal gap. Of note, glottic closure did normalize or improve in
11 of the original 16 patients in whom closure was
impaired. The primary means by which steroid injection
appears to improve voice production, though, is through
improved pliability.
Multiple techniques are currently employed to treat vocal
fold scar. Medialization thyroplasty29 is employed to reduce
glottic insufficiency caused by scar-related contracture, but

Downloaded from oto.sagepub.com at CORNELL UNIV WEILL MED COLG on August 17, 2016
Young et al 7

Figure 5. Phonation threshold pressure before and after steroid

Figure 4. Perceptual rating scales before and after steroid injec- injection. Bars represent mean score, and error bars represent
tion. Bars represent mean score, and error bars represent stan- standard error of the mean. Phonation threshold pressure
dard error of the mean. All scores decreased significantly after decreased significantly after injection.
injection except asthenia.

and stroke, office procedures cost less,35 require less time,

it involves a neck incision and does not address the loss of
lamina propria pliability. Injection laryngoplasty offers a
less invasive alternative but is temporary and has not been
shown to improve the mucosal wave. Microsurgical proce-
dures, such as microflap elevation with scar lysis, have been
a vital component of treatment30 but often require extended
mucosal disruption and prolonged recovery time. Various
implants have been used, including autologous fat31,32 and
collagen.33 More recently, the role of the photoangiolytic
laser in scar remodeling has been investigated.34
While these are important treatment options, voice out-
comes are inconsistent,26,27 and some, such as microflap eleva-
tion, require general anesthesia and direct microlaryngoscopy
with suspension. We report outcomes of office-based steroid
injection, reflecting a general trend toward rendering treatment
in the office rather than the operating room. Office-based treat-
ments offer several advantages. In addition to avoiding the
risks of general anesthesia, including myocardial infarction
and avoid potential complications of microlaryngoscopy,
such as dental injury and dysgeusia.36 With appropriate
patient selection, office procedures are safe.37-40 Still, patients
with advanced airway compromise or concerning medical
comorbidities are not appropriate candidates, and some
patients will demonstrate anxiety to these procedures.
Importantly, attempting an office procedure does not preclude
subsequent operative intervention. Also, since most patients
considered for an operative intervention have severe voice
changes or advanced scar, office-based steroid injection
offers a less invasive option for patients with less severe scar
for whom an operation may not be warranted.
Glucocorticoids affect intracellular mechanisms to reduce
vocal fold inflammation and collagen deposition.41 Side
effects are substantially decreased when administered as a
soft tissue injection. Local injection also allows for a higher
concentration of the glucocorticoid in the affected tissue.
Potential local adverse effects include thinning of the

Table 4. Videostroboscopic Data.

Preinjection Postinjection

Parameter n Normal Abnormal Normal Abnormal Improvedb P Valuea

Vocal fold edge 18 2 16 3 6 9 .004

Glottic closure 19 3 16 9 5 5 .003
Amplitude
Right 19 6 13 8 10 1 .248
Left 19 5 14 8 10 1 .134
Mucosal wave
Right 19 5 14 6 9 4 .016
Left 19 2 17 5 8 6 .131
a
P values represent result of McNemars tests comparing number of patients with normal and abnormal parameters preinjection versus the number with
normal 1 improved and abnormal parameters postinjection.
b
Improved indicates movement toward normal without reaching normal.

Downloaded from oto.sagepub.com at CORNELL UNIV WEILL MED COLG on August 17, 2016
8 OtolaryngologyHead and Neck Surgery
overlying epithelium or muscle atrophy with subsequent
glottal insufficiency.42 This appears to be rare and transient,
occurring only in 4 of 80 patients and resolving by 2
months postinjection in a study on patients undergoing ster-
oid injection for vocal nodules.43 Reversible atrophy has
been observed in 2 patients undergoing repeated injections
for scar.23 In an animal study, mild muscle atrophy was
observed in 4 of 24 rabbits undergoing triamcinolone injec-
tion, but the atrophy resolved by 12 weeks after the injec-
tion.44 Of note in our study, there was no change in flow
after the single steroid injection.
Limitations of this study include concurrent voice therapy,
lack of control group, and lack of long-term follow-up. The
retrospective nature of the study, combined with the lack of a
control group undergoing serial voice assessment without
steroid injection, makes it difficult to say definitively that the
changes observed were due to the injection rather than other
factors. Notably, the majority of patients (23 of 25) partici-
pated in voice therapy, and a significant decrease in reflux
symptom index scores also occurred. These factors may also
have contributed to improved vocal function. The specific
benefit of voice therapy versus injection is not certain and
would be worth evaluating in a randomized or serial therapy
study. Duration of benefit for a single injection and optimal
timing of serial injections are unknown. Patients in the
Mortensen and Woo study with scar received between 1 and
10 injections, once every 6 and 12 weeks until improved.13
Literature for hypertrophic and keloid scar suggests that
injections be performed every 4 and 6 weeks, but there is no
standard protocol.45 More frequent injections to the vocal
fold can cause atrophy and result in worsening dysphonia.23
The longest reported follow-up for vocal fold steroid injec-
tion is 6 months in a subset of patients.24 For cutaneous scar,
median time to recurrence is 12.9 months.46 Further investi-
gation is needed to ensure lasting results and develop an opti-
mal protocol that avoids both the risk of scar recurrence and
the risk of vocal fold atrophy.
Despite these limitations, the changes in a variety of sub-
jective and objective parameters provide preliminary evi-
dence for the efficacy of steroid injection for vocal fold
scar. Importantly, the intervention is low risk and can be
performed in the office. Failure to improve after injection
does not preclude performance of future, more invasive pro-
cedures and is unlikely to worsen the patients voice. Based
on the improvements observed in this study, steroid injec-
tion could be considered a viable treatment option for
patients with mild to moderate vocal fold scar.
Acknowledgments
We thank Dr Glen Leverson for his assistance with the statistical
analysis performed in this study.
Author Contributions
William G. Young, design of work; acquisition and interpretation
of data; drafting of manuscript; final approval of manuscript;
accountable for all aspects; Matthew R. Hoffman, design of work;
acquisition and interpretation of data; drafting of manuscript; final
Downloaded from oto.sagepub.com at CORNELL UNIV WEILL MED COLG on August 17, 2016
approval of manuscript; accountable for all aspects; Ian J.
Koszewski, interpretation of data; critical revision of manuscript;
final approval of manuscript; accountable for all aspects; Chad W.
Whited, interpretation of data; critical revision of manuscript; final
approval of manuscript; accountable for all aspects; Brienne N.
Ruel, interpretation of data; critical revision of manuscript; final
approval of manuscript; accountable for all aspects; Seth H. Dailey,
design of work and interpretation of data; critical revision of manu-
script; final approval of manuscript; accountable for all aspects.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
References
1. Benninger MS, Alessi D, Archer S, et al. Vocal fold scarring:
current concepts and management. Otolaryngol Head Neck
Surg. 1996;115:474-482.
2. Hirano M.Phonosurgery: basic and clinical investigations.
Otologia (Fukuoka). 1975;21:239-440.
3. Li J, Chen J, Kirsner R. Pathophysiology of acute wound heal-
ing. Clin Dermatol. 2007;25:9-18.
4. Wilgus TA, Roy S, McDoaniel JC. Neutrophils and wound
repair: positive actions and negative reactions. Adv Wound
Care. 2013;2:379-88.
5. Young A, McNaught CE. The physiology of wound healing.
Surgery. 2011;29:475-479.
6. Beldon P.Basic science of wound healing. Surgery. 2010;28:
409-412.
7. Thibeault SL, Gray SD, Bless DM, Chan RW, Ford CN.
Histologic and rheologic characterization of vocal fold scar-
ring. J Voice. 2002;16:96-104.
8. Ketchum LD, Smith J, Robinson DW, Masters FW. The treat-
ment of hypertrophic scar, keloid and scar contracture by triam-
cinolone acetonide. Plast Reconstr Surg. 1966;38:209-218.
9. Alaish SM, Yager DR, Diegelmann RF, Cohen IK. Hyaluronic
acid metabolism in keloid fibroblasts. J Pediatr Surg. 1995;30:
949-952.
10. McCoy BJ, Diegelmann RF, Cohen IK. In vitro inhibition of
cell growth, collagen synthesis, and prolyl hydroxylase activity
by triamcinolone acetonide. Exp Biol Med. 1980;163:216-222.
11. Tateya I, Omori K, Kojima H, Hirano S, Kaneko K, Ito J.
Steroid injection to vocal nodules using fiberoptic laryngeal
surgery under topical anesthesia. Eur Arch Otorhinolaryngol.
2004;261:489-492.
12. Yanagihara N, Azuma F, Koike Y, Honjo I, Imanishi Y.
Intracordal injection of dexamethasone. Practica Otorhinolaryngol.
1964;57:496-500.
13. Mortensen M, Woo P. Office steroid injections of the larynx.
Laryngoscope. 2006;116:1735-1739.
14. Koufman JA, Blalock D.Is voice rest never indicated? J Voice.
1989;3:87-91.
15. Rousseau B, Gutmann ML, Mau T, et al. Randomized con-
trolled trial of supplemental augmentative and alternative com-
munication versus voice rest alone after phonomicrosurgery.
Otolaryngol Head Neck Surg. 2015;152:494-500.
Young et al
16. Jacobson BH, Johnson A, Grywalski C, et al. The Voice
Handicap Index (VHI): development and validation. Am J
Speech Lang Pathol. 1997;6:66-70.
17. Bach KK, Belafsky PC, Wasylik K, Postma GN, Koufman JA.
Validity and reliability of the glottal function index. Arch
Otolaryngol Head Neck Surg. 2005;131:961-964.
18. Karnell MP, Melton SD, Childes JM, et al. Reliability of
clinician-based (GRBAS and CAPE-V) and patient-based (V-
RQOL and IPVI) documentation of voice disorders. J Voice.
2007;21:576-590.
19. Belafsky PC, Postma GN, Koufman JA. Validity and reliability
of the reflux symptom index (RSI). J Voice. 2002;16:274-277.
20. Hirano Hirano M. Clinical Examination of Voice. New York,
NY: Springer Verlag; 1981.
21. Wuyts FL, de Bodt MS, Molenberghs G, et al. The dysphonia
severity index: an objective measure of vocal quality based on
a multiparameter approach. J Speech Lang Hear Res. 2000;43:
796-809.
22. Mortensen M.Laryngeal steroid injection for vocal fold scar.
Curr Opin Otolaryngol Head Neck Surg. 2010;18:487-491.
23. Shi LL, Giraldez-Rodriguez LA, Johns MM 3rd. The risk of
vocal fold atrophy after serial corticosteroid injections of the
vocal fold [published online November 24, 2015]. J Voice.
24. Woo JH, Kim DY, Kim JW, Oh EA, Lee SW. Efficacy of per-
cutaneous vocal fold injections for benign laryngeal lesions:
prospective multicenter study. Acta Otolaryngol. 2011;131:
1326-1332.
25. De Bodt MS, Wuyts FL, Van de Heyning PH, Croux C. Test-
retest study of the GRBAS scale: influence of experience and
professional background on perceptual rating of voice quality.
J Voice. 1997;11:74-80.
26. Hansen JK, Thibeault SL. Current understanding and review of
the literature: vocal fold scarring. J Voice. 2006;20:110-120.
27. Friedrich G, Dikkers FG, Remacle M, et al. Vocal fold scars:
current concepts and future directions. Consensus report of the
phonosurgery committee of the European Laryngological Society.
Eur Arch Otorhinolaryngol. 2013;270:2491-2507.
28. Chan TW, Titze IR. Dependence of phonation threshold pres-
sure on vocal tract acoustics and vocal fold tissue mechanics.
J Acoust Soc Am. 2006; 119:2351-2362.
29. Isshiki N, Morita H, Okamura H, Hiramoto M. Thyroplasty as
a new phonosurgical technique. Acta Otolaryngol. 1974;78:
451-457.
30. Bouchayer M, Cornut G. Microsurgery for benign lesions of
the vocal folds. Ear Nose Throat J. 1988;67:446-464.
31. Sataloff RT, Spiegel JR, Hawkshaw M, Rosen DC, Heuer RJ.
Autologous fat implantation for vocal fold scar: a preliminary
report. J Voice. 1997;11:238-246.
Downloaded from oto.sagepub.com at CORNELL UNIV WEILL MED COLG on August 17, 2016
9
32. Shaw GY, Szewczyk MA, Searle J, Woodruff J. Autologous
fat injection into the vocal folds: technical considerations and
long-term follow-up. Laryngoscope. 1997;107:177-186.
33. Ford CN, Bless DM, Loftus JM. Role of injectable collagen in
the treatment of glottic insufficiency: a study of 119 patients.
Ann Otol Rhinol Laryngol. 1992;101:237-247.
34. Prufer N, Woo P, Altman KW. Pulse dye and other laser treat-
ments for vocal scar. Curr Opin Otolaryngol Head Neck Surg.
2010;18:492-497.
35. Rees CJ, Postma GN, Koufman JA. Cost savings of unsedated
office-based laser surgery for laryngeal papillomas. Ann Otol
Rhinol Laryngol. 2007;116:45-48.
36. Klussmann JP, Knoedgen R, Wittekindt C, Damm M, Eckel
HE.Complications of suspension laryngoscopy. Ann Otol Rhinol
Laryngol. 2002;111:972-976.
37. Rees CJ, Halum S, Wijewickrama RC, Koufman JA, Postma
GN. Patient tolerance of in-office pulsed dye laser treatments
to the upper aerodigestive tract. Otolaryngol Head Neck Surg.
2006;134:1023-1027.
38. Andrade Filho PA, Carrau RL, Buckmire RA. Safety and cost-
effectiveness of intra-office flexible videolaryngoscopy with
transoral vocal fold injection in dysphagic patients. Am J
Otolaryngol. 2006;27:319-322.
39. Zeitels SM, Burns JA. Office-based laryngeal laser surgery
with the 532-nm pulsed-potassium-titanyl-phosphate laser.
Curr Opin Otolaryngol Head Neck Surg. 2007;15:394-400.
40. Koszewski IJ, Hoffman MR, Young WG, Lai Y, Dailey SH.
Office-based photoangiolytic laser treatment of Reinkes
edema: safety and voice outcomes. Otolaryngol Head Neck
Surg. 2015;152:1075-1081.
41. Campagnolo AM, Tsuji DH, Sennes LU, Imamura R, Saldiva
PHN. Histologic study of acute vocal fold wound healing after
corticosteroid injection in a rabbit model. Ann Otol Rhinol
Laryngol. 2010;119:133-139.
42. Tateya I. Laryngeal steroid injection. Curr Opin Otolaryngol
Head Neck Surg. 2009; 17:424-426.
43. Lee SH, Yeo JO, Choi JI, et al. Local steroid injection via the
cricothyroid membrane in patients with vocal nodule. Arch
Otolaryngol Head Neck Surg. 2011;137:1011-1016.
44. Jin HJ, Lee SH, Lee SU, et al. Morphological and histological
changes of rabbit vocal fold after steroid injection. Otolaryngol
Head Neck Surg. 2013;149:277-283.
45. Roques C, Teot L.The use of corticosteroids to treat keloids: a
review. Int J Low Extrem Wounds. 2008;7:137-145.
46. Cosman B, Crikelair CF, Ju DMC, Gaulin JC, Lattes R. The
surgical treatment of keloids. Plast Reconstructive Surg. 1961;
27:335-358.