Otolaryngology– Head and Neck Surgery
April 2002 VOLUME 126 NUMBER 4
ORIGINAL ARTICLES Management of common voice problems: Committee report
STEVEN M. ZEITELS, MD, FACS,ROY R. CASIANO, MD, FACS, GLENDON M. GARDNER, MD, NORMAN D. HOGIKYAN, MD, FACS, JAMES A. KOUFMAN, MD, FACS, and CLARK A. ROSEN, MD, FACS, Boston, Massachusetts, Miami, Florida, Detroit and Ann Arbor, Michigan, Winston-Salem, North Carolina, and Pittsburgh, Pennsylvania
OBJECTIVE: This report provides the reader with a decade, there has been a dramatic expansion of state-of-the-art update on a number of common knowledge regarding a variety of voice disorders voice problems that require phonosurgical inter- and associated treatment. There has been a con- vention. vergence of basic science investigations in anato- STUDY DESIGN AND SETTING: This multiauthor review my,physiology, and pathology with clinical trials of is not a position statement of the American treatment, both surgical and nonsurgical. This infor- Academy of Otolaryngology–Head and Neck mation should provide the reader with current Surgery (AAOHNS) and may reflect institutional insight into critical management issues of the afore- preference and/or bias. It arose from a panel dis- mentioned disorders. (Otolaryngol Head Neck Surg cussion at the AAOHNS meeting in 2000. 2002;126:333-48.) RESULTS: We provide a review of the genesis and management of papillomatosis, dysplastic glottal Laryngology developed as a medical and surgical epithelium, arytenoid granulomas, Reinke’s specialty in eastern Europe in the late 1850s1,2 as a edema, and vocal-fold paralysis. result of Garcia’s3 investigations into singing CONCLUSIONS AND SIGNIFICANCE: In the past phonation. Management of the human voice has
From the Department of Otology and Laryngology, Harvard Pittsburgh School of Medicine, and University of Medical School, and the Division of Laryngology, Pittsburgh Voice Center (Dr Rosen). Massachusetts Eye and Ear Infirmary (Dr Zeitels), the Presented as a panel from the Voice and Swallowing Department of Otolaryngology, University of Miami Committee at the annual meeting of the American Academy School of Medicine (Dr Casiano), the Department of of Otolaryngology–Head and Neck Surgery, Washington, Otolaryngology–Head & Neck Surgery, Henry Ford Health DC, September 24-27, 2000. Systems (Dr Gardner), the Department of Otolaryngology, Reprint requests: Steven M. Zeitels, MD, FACS, Division of University of Michigan Medical School, Division of Vocal Laryngology, Massachusetts Eye and Ear Infirmary, 243 Arts–University of Michigan School of Music, and Charles St, Boston, MA 02114; e-mail, smzeitels@ University of Michigan Vocal Health Center (Dr meei.harvard.edu Hogikyan), the Department of Otolaryngology, Wake Copyright © 2002 by the American Academy of Oto- Forest University School of Medicine, and Center for Voice laryngology–Head and Neck Surgery Foundation, Inc. Disorders of Wake Forest University (Dr Koufman), and 0194-5998/2002/$35.00 + 0 23/1/123546 the Department of Otolaryngology, University of doi:10.1067/mhn.2002.123546
333 Otolaryngology– Head and Neck Surgery 334 ZEITELS et al April 2002
been an enduring and crucial area of investigation the human body; the delicacy of interdependent throughout laryngologic history. The importance management is sustained by surgeons, speech lan- of a reliable human voice has become increasingly guage pathologists, singing-voice teachers, and evident during the development of the communi- family members. Tremendous advancements have cation age of the 20th century and will become been achieved during the past 10 years, and the even more critical in the 21st century.4 Vocal early part of the twenty-first century should bring impairment can result in loss of productivity in the many more promising accomplishments. workplace and become a psychosocial problem. Surgical research and investigations into the phys- RECURRENT RESPIRATORY iologic function underlying human laryngeal voice PAPILLOMATOSIS production have led to a watershed of operations Background designed to restore and improve the quality of the Recurrent respiratory papillomatosis (RRP) of human voice. the upper airway and digestive tract is a severe and The term phonosurgery was developed by von potentially fatal disease that frequently is a com- Leden in the early 1960s and refers to surgical pro- plex management problem for both the patient and cedures that maintain or improve the human voice. the otolaryngologist. Phonosurgery includes (1), phonomicrosurgery, or RRP can occur on any mucosal surface of the endoscopic microsurgery of the vocal folds, (2) upper aerodigestive tract, but it most commonly laryngoplastic phonosurgery, or open neck surgery occurs in the larynx. Recently, there have been sig- that restructures the laryngeal cartilage framework nificant advancements in the understanding of and soft tissues, (3) injection techniques, which molecular mechanisms underlying RRP as well as include the placement of medications as well as in the clinical treatment of the disease. Im- synthetic and organic biological substances, and provements in DNA-testing technology, specifical- (4) neural reinnervation of the larynx. ly Southern blot methodology, have facilitated Successful management of the human voice definitive identification of the human papilloma typically requires the use of laryngeal stroboscopy. virus (HPV) as the etiologic source of RRP.6 This This device, which was perfected in 1895,5 allows scientific progress is encouraging for the future for clinical assessment of vocal fold vibration and enhanced care and treatment of patients with RRP. oscillation, a fundamental component of voice pro- The most common HPV types involved in RRP duction. The widespread use of stroboscopy hall- are HPV-6 and HPV-11. It is important to note that marked the instillation of physiologic principles of the HPV infection occurs in epithelial cells and is laryngeal sound production into the design of new not located in any layer deeper than the epithelium. surgical procedures. This resulted in paradigmatic This, of course, plays an important role when it shifts in the medical and surgical management of comes to surgical removal of RRP. Equally impor- voice disorders during the past decade. The proce- tant regarding the surgical treatment for RRP is a dural innovations have been fueled by internation- study by Steinberg et al7 that identified the HPV in al collaboration and driven by improved normal-appearing mucosa in patients with RRP. understanding of the physiologic function of vocal This finding had the impact of directing the sur- fold oscillation. geon to not use the axiom that “more is better” Recent successes have led to enthusiasm for when treating RRP surgically. future developments, similar to the nascent era of laryngology in the middle nineteenth century. Clinical Presentation Laryngeal and voice problems are universal When the diagnosis of RRP, juvenile or adult, is throughout the world regardless of age, gender, or made, it is important to establish thorough lines of social stratification. The inability to communicate communication with the patient and/or the family vocally can be crippling to the teacher as well as regarding the nature of the disease and future treat- the parent, laborer, or performing artist. The larynx ment. The involved individual(s) should be offered has the most complex voluntary motor function in comprehensive education regarding background Otolaryngology– Head and Neck Surgery Volume 126 Number 4 ZEITELS et al 335
knowledge of RRP, including information regard- geal mucosa often require different surgical ing RRP support groups, specifically, the approaches and instrumentation (CO2 laser, micro- Recurrent Respiratory Papillomatosis Foundation surgical cold steel, and microdebrider). (www.rrpf.org). The importance of this type of Approaches for surgical removal of RRP are patient education and investment of time and ener- controversial; instrumentation should be individu- gy cannot be overemphasized. alized and selected with care to optimize precision. Patients with RRP are tremendously challeng- It must be emphasized that RRP is an epithelial ing. When aggressive recurrent disease is encoun- disease and that it is critical to preserve the under- tered, the surgeon and patient must delicately lying superficial lamina propria (SLP) and other balance airway safety, the effects of multiple gen- vital structures, such as anterior commissure ten- eral anesthesia procedures, and quality of life and don and vocal process. Furthermore, the natural employment disturbance from the vocal dysfunc- history of RRP is that it recurs, which usually tion and procedural disability. This often requires necessitates multiple procedures in the lifetime of extensive communication to ensure that the a patient. These factors must be omnipresent in the patient’s and surgeon’s goals are mutually aligned. surgeon’s mind because the preservation of normal Patients who have respiratory papillomatosis of laryngeal tissue will facilitate optimal function for the glottis most frequently present with hoarse- the future, since a medical solution will ultimately ness. Commonly, the glottal disease is confined to be conceived. At present, the preferred treatment the musculomembranous region, although it is not technique of glottic RRP is microsurgical cold unusual to find extension in the interarytenoid steel excision10 using phonomicrosurgical treat- region, ventricle, and subglottis. Exophytic disease ment equipment and techniques (Fig 1A to D). can lead to stridor and airway compromise, espe- Microlaryngoscopy for RRP should be per- cially in children. formed with the largest possible laryngoscope for optimal visualization of the disease and surgical Treatment removal.8 An important adjunct for evaluating and It is important to remember that RRP is typical- subsequently treating patients with RRP during ly not cured with surgical removal of the disease. microlaryngoscopy is the use of angled telescopes Thus, a more aggressive resection does not result through the suspended laryngoscope.9 The 30° and in an improved chance for a cure or a decreased 70° telescopes are of special importance for visu- chance for recurrence. The general behavior of the alizing the undersurface of the true vocal fold, ven- disease usually leads to eventual recurrence. tricle, anterior commissure, and posterior glottis. Therefore, all surgical treatment, regardless of the The telescopes can also be helpful during RRP methodology of the removal, should be based on resection and are important for establishing the the principles of precise, conservative removal of adequacy of treatment at the completion of each the disease. The importance of gentle, precise sur- surgical session. gical debulking/removal is paramount to the surgi- Subepithelial infusion11 enhances phonomicro- cal management of RRP. surgical management in a number of ways. The Ideally, surgical intervention should be done by infusion positions the disease toward the center of individuals with high-level expertise in microsur- the laryngoscope, which improves visualization gical procedures of the larynx. Successful manage- and precise surgical removal. In addition, the dis- ment is dependent on skilled operating room ease is separated from important, delicate underly- supporting staff, communication with anesthesiol- ing layered microstructures (SLP), which should ogy colleagues, and availability of current micro- be preserved during surgical removal of the RRP. surgical instrumentation. This includes current Adjunctive treatment options for RRP have laryngoscopes8 and hand instruments as well as been appealing for years, especially given the angled telescopes.9 It is crucial that the surgeon be recalcitrant and recurrent nature of the disease. facile with several surgical techniques to remove This is especially true because of the conceptual the disease because the different regions of laryn- understanding that RRP is an infectious process, a Otolaryngology– Head and Neck Surgery 336 ZEITELS et al April 2002
viral infestation of the upper aerodigestive tract gical management must be regarded as primarily mucosa, that surgery does not fully eradicate. palliative, and this has been greatly enhanced by Adjunctive treatments are all presently done on an using techniques of modern-day phonomicro- experimental basis. surgery for precise and conservative microsurgical Photodynamic therapy has been studied exten- removal of papilloma disease. Advancement of the sively; however, to date there is no conclusive evi- field of experimental/adjunctive treatment for RRP dence demonstrating either a high degree of is dependent on future research funding efforts and success or a cure.12 Furthermore, side effects with the ethical use of new methods. Specifically, earlier, older photosensitizing agents have been experimental treatments should be applied in a severe. Research is being done with newer agents systemic and methodic fashion as opposed to anec- that will, it is hoped, be effective and have minimal dotal and trend-based options. side effects. More recently, pulsed-dye laser pho- toangiolysis of the microcirculation associated MANAGEMENT OF THE WHITE VOCAL with papillomatosis offers an exciting new surgical FOLD LESION treatment that may allow for clinic treatment of Background selected patients and enhanced vocal outcomes.13 When confronted with a white lesion on the Indole-3-carbinol (I3C) has been used for RRP vocal fold, the surgeon is often confronted with a with moderate success.14 I3C is a chemical found myriad of management dilemmas. Is the lesion in high concentration in cruciferous vegetables malignant? Should the lesion be biopsied or just (cabbage, broccoli, cauliflower, and Brussels followed closely? If a biopsy is performed, should sprouts) and has been found to be active in modu- it be a complete excision or a random biopsy? If lating estrogen metabolism that affects HPV activ- the pathology report is consistent with a nonmalig- ity. In addition, I3C has been shown in the nant diagnosis, how should the patient be man- laboratory to suppress RRP growth in vitro, as well aged? Are there any medical options to reduce the as to reduce RRP growth in an animal model. A frequency of recurrence? Adding to the confusion prospective, open-label clinical study demonstrat- is the natural tendency for these lesions to partial- ed significant reduction of RRP new growth in one ly or completely regress, stabilize without further third of patients with no adverse side effects. I3C progression, or progress to malignant degenera- is taken orally and appears to successfully sup- tion. Furthermore, white lesions may be found in press new papilloma growth in a significant por- association with a variety of other benign laryn- tion of patients with RRP. geal lesions including vocal fold polyps, nodules Intralesional injection of cidofovir is the most or cysts, laryngeal papillomas, and granulomas. recent adjunctive/experimental treatment for RRP.15 Cidofovir is a known antiviral agent that is Clinical Presentation approved by the Food and Drug Administration for There have been a variety of clinical terms to cytomegalovirus retinitis. Preliminary experience describe white lesions of the vocal fold: leuko- with intralesional injection of the RRP disease plakia, hyperkeratosis, keratosis, pachydermia, with cidofovir has been highly favorable. and epithelial hyperplastic lesion. However, it is However, no long-term results with respect to side very difficult to accurately predict which white effects, complications, and cessation of treatment lesion will progress into carcinoma based solely on have been demonstrated. A multicenter, prospec- clinical appearance. Studies have shown that the tive randomized trial is planned in the near future surface appearance bares little correlation with the for this promising treatment option. underlying histopathology.16 Simple hyperplasia, RRP continues to be an extremely challenging dysplasia, and/or carcinoma can all coexist in the disorder for patients, their families, and clinicians. same lesion. Despite this, there are a few clinical However, significant advances in HPV viral signs that are suggestive of invasive carcinoma. research and the subsequent adjunctive treatments Furthermore, stroboscopy has not been a reliable hold great promise for the future. At present, sur- method of determining the presence of cancer or Otolaryngology– Head and Neck Surgery Volume 126 Number 4 ZEITELS et al 337
the depth of invasion if cancer is known to be pre- all been23,24 epidemiologically associated with sent.17 In decreasing order of importance, ulcera- laryngeal carcinogenesis. Therefore, the patient tion, erythroplasia, surface granularity, increased needs appropriate counseling regarding these risk keratin thickness (verrucous appearance), in- factors as part of the overall treatment plan. creased size, recurrence after excisional biopsies, A 1-month trial of conservative measures is and long duration have all been associated with reasonable in the absence of any worsening of carcinoma.16 vocal symptoms, an enlarging lesion, or clinical Histopathologically, white lesions on the vocal signs suggestive of invasive carcinoma. fold may be classified as hyperplasia, metaplasia, Conservative measures include instructing the or dysplasia. Dysplasia has been further classified patient on proper hydration, reduction of dehy- as being mild, moderate, or severe. In mild dyspla- drants (ie, caffeine and alcohol), and elimination sia, one sees simple hyperplasia with a more or of any vocal abuse tendencies. The patient is also less extended keratosis but without actual dysplas- strongly advised to stop smoking and/or to seek tic changes or mitotic figures and cellular atypia. treatment for their ethanol abuse. Other risk fac- In moderate dysplasia, there is hyperplasia with or tors, such as laryngotracheal reflux, also need to without keratosis but with cellular atypia. With be addressed at this time. severe dysplasia, there is significant cellular atyp- Chemoprevention with retinoids, selenium, and ia present in various epithelial layers without other agents is still controversial. However, a extension beyond the basement membrane (as seen recent report evaluated the clinical response to in carcinoma in situ). retinol palmitate for laryngeal hyperplasia with an There have been a number of recent studies induction dose of at least 300,000 IU followed by examining whether histopathologic and/or a maintenance dose of 150,000 IU.25 There was a immunohistochemical factors can predict progres- complete response in 75% of the patients and a sion from dysplasia toward infiltrative carcinoma. partial response in the remainder. None of the Eventual progression to carcinoma has been lesions progressed to cancer. reported in approximately 2% to 12% of mildly One principal drawback to using retinoids is dysplastic lesions, 9% to 33% of moderately dys- that the lesions tend to recur when treatment is dis- plastic lesions, and 13% to 44% of severely dys- continued. Also, there may be significant side plastic lesions.18,19 In addition, recent studies with effects due to mucocutaneous toxicity. In addition, immunohistochemical markers, such as the Ki-67 recent reports suggest an increased incidence of nuclear protein, Langerhans cell density, prolifer- lung cancer when beta-carotene was used for pri- ating cell nuclear antigen (PCNA), p53 suppres- mary cancer prevention in heavy smokers.26,27 sion gene, and CD44 glycoprotein tumor Therefore, patients need to be cautioned regarding immunohistochemical analysis, have shown future potential adverse side effects. potential in accurately predicting progression to Radiation therapy has not been shown to prevent carcinoma.20-22 However, further study on a larger the progression of dysplastic lesions to carcinoma; in series of patients is warranted before any firm rec- fact, it may even precipitate malignant degeneration. ommendations can be made regarding the use of Therefore, radiation therapy should be reserved for these markers on a routine clinical basis. carcinoma in situ or invasive carcinoma. If the patient does not improve with conserva- Treatment tive measures, then an excisional biopsy is per- The initial management of a patient with a white formed (Fig 2A to D). Due to the multicentricity of lesion on the vocal fold should begin with a deter- cancer in hyperplastic lesions, random biopsies are mination of whether this is a low- or high-risk lesion discouraged. Excisional biopsy is performed with based on history and physical examination. Tobacco special emphasis on preserving the structural and ethanol abuse, occupational risk factors, diet integrity of the deeper uninvolved layers of the and vitamin deficiency, irradiation exposure, viral vocal fold and surrounding normal mucosa.16 exposure (ie, HPV), and laryngotracheal reflux have Routine “vocal fold stripping” is not advised. Otolaryngology– Head and Neck Surgery 338 ZEITELS et al April 2002
A B
C D
Fig 1. A, An exophytic single focus of papilloma on the right vocal fold is seen subsequent to subepithelial infusion of saline solution and 1:10,000 epinephrine into the superficial lamina propria. B, The lesion is retracted as a microflap, and a dissector is used to sweep the superficial lamina propria from the basement membrane back to the patient. Note the lack of bleeding secondary to the infusion. C, The microflap con- taining the lesion is retracted, and an upturned scissors is used to complete the excision. D, The lesion has been completely resected.
In the absence of carcinoma, most hyperplastic muscle suggests an invasive carcinoma or sig- lesions occur on the superior or ventricular surface nificant fibrosis from prior surgery. With carci- of the vocal fold.16 Therefore, dissection onto the noma in situ or invasive carcinoma, a more phonating edge of the vocal fold is often not nec- generous resection of mucosa and/or underlying essary for complete excision. The lesion is careful- ligament and muscle may be necessary (ie, a ly dissected off the deeper layers of the lamina cordectomy). However, the patient has to be propria using precise phonosurgical technique. advised that the degree of permanent vocal fold This minimizes the chances of adversely affecting dysfunction is proportional to the amount of vocal function due to extensive vocal fold fibrosis. vocalis muscle removed. Also, anterior commis- At the completion of the surgical procedure, the sure involvement may adversely affect oncolog- specimen is labeled and sent for serial section to ic outcome with transoral endoscopic resection avoid missing a focus of carcinoma. if the lesion cannot be adequately exposed.28 Difficulty in dissecting the lesions off the Therefore, in this scenario, radiation therapy deeper layers of the lamina propria or vocalis may be more advisable. Otolaryngology– Head and Neck Surgery Volume 126 Number 4 ZEITELS et al 339
A B
C D
Fig 2. A, There are bilateral irregular lesions of the superior and medial surface of the vocal folds. There is a T1, N0, M0 squamous cell carcinoma on the left and keratosis with atypia on the right. B, A subepithelial infusion of saline solution and epinephrine has been placed on the left. C, The dissection within the normal superficial lamina propria is performed to encompass the entire left lesion. The dissection on the medial and subcordal surface has not begun yet. D, The microinvasive carcinoma is excised at its caudal margin with an upturned scissors.
ARYTENOID GRANULOMAS successful long-term outcomes, each of the under- lying causes needs to be identified and corrected. Background Contact ulcers and granulomas were the first Clinical Presentation laryngeal conditions to be related to reflux dis- For patients with granulomas, the history is ease.29 In addition to laryngopharyngeal reflux, important and should focus on the onset of symp- authors writing on the topic have implicated many toms and findings. Pain and odynophonia are more other etiologic factors, including vocal trauma/ common than significant vocal change. Did the abuse, chronic throat clearing, endotracheal intu- granuloma occur after intubation, trauma, or viral bation, and vocal fold paresis.30-32 In most cases, infection? The granuloma patient should be rou- the etiology of granulomas is multifactorial, and tinely evaluated for signs and symptoms of laryn- several underlying etiologic factors may be present gopharyngeal reflux and for glottal closure in an individual patient. Vocal fold granulomas are problems. Symptoms associated with the latter are common and relatively recalcitrant to therapy, and effortful phonation, vocal fatigue, breathiness, and surgery alone is seldom effective.32 To achieve odynophonia. At Wake Forest Medical Center, Otolaryngology– Head and Neck Surgery 340 ZEITELS et al April 2002
A B Fig 3. A, Bilateral granulomas are seen. The endotracheal tube is positioned anterior to the laryngoscope. B, Subsequent to a subepithelial infusion, the granuloma is retracted and an upturned microscissors is used to resect the lesion without disturbing the arytenoid perichondrium.
most granuloma patients now undergo a complete Most patients with granulomas will show signs medical evaluation that includes (1) fiberoptic and symptoms of laryngopharyngeal reflux. With laryngoscopy, (2) acoustical (voice laboratory) or without reflux testing, if such signs and symp- analysis, (3) laryngeal electromyography, and (4) toms are present, we recommend use of a double- reflux (pH) testing. dose proton pump inhibitor, with the first dose Fiberoptic laryngoscopy is important to evaluate being given in the morning before breakfast and for subtle movement disorders consistent with a the second in the afternoon before the evening diagnosis of vocal fold paresis. In addition, laryn- meal. Many patients with granulomas will have geal biomechanics are assessed to determine the resolution on antireflux treatment alone; however, potential role of abusive vocal behaviors. Acoustical it is not unusual for such granulomas to take 6 to 8 analysis is performed primarily to rule out vocal months to resolve.32 Patients with granulomas are fold paresis. In many cases of paresis, closure on seen in the clinic approximately every 2 months, electroglottography in the unloaded phase will drop and if there is no improvement based on the laryn- into the 30% to 40% range. This is characteristic of geal examination, the dose of proton pump glottal insufficiency, regardless of the cause. inhibitor is increased. (We have used doses of With increasing frequency, we perform laryn- omeprazole as high as 40 mg 4 times a day in some geal electromyography on granuloma patients. patients with granulomas.) At high doses, if treat- Finally, ambulatory double-probe (simultaneous ment still seems to be failing, repeat pH testing is esophageal and pharyngeal) pH monitoring is per- carried out to evaluate drug efficacy, and in some formed. When this comprehensive diagnostic bat- cases fundoplication is recommended. The key to tery is used, we have found that many patients successful antireflux management in this group of have more than one underlying cause for their patients is to not assume or expect resolution with- granulomas.32 in the first few months of treatment. Some patients exhibit chronic throat clearing Treatment and abusive vocal behaviors. In these cases, voice Treatment options include voice rest, voice ther- therapy by a trained speech-language pathologist apy, antireflux therapy, surgical removal (Fig 3A is indicated. In addition, patients who have persis- and B), botulinum toxin injections, and medializa- tently abnormal biomechanics should be evaluated tion laryngoplasty.32-35 The remainder of this sec- for vocal fold paresis. It has been our experience tion is devoted to the Wake Forest algorithm for that many such patients have underlying vocal fold management of arytenoid granulomas. paresis and that the abnormal biomechanics are Otolaryngology– Head and Neck Surgery Volume 126 Number 4 ZEITELS et al 341
A B
C
Fig 4. A, This patient presented with severe polypoid corditis (“Reinke’s edema”). She had laryngeal sleep apnea, as well as a fundamental frequency of approximately 90 Hz. B, A microsuction is used to remove the relatively acellular swollen tissue for more normal contouring. C, The image in B at a higher magnifi- cation. There is excellent apposition of the epithelial edges, and the vocal folds are more appropriately contoured. (All images are courtesy of Singular/Thompson Learning.)
compensatory for an underlying hypokinetic laryn- The most controversial area of granuloma man- geal condition.33 agement is surgical removal. In our opinion, there It has been recommended that botulinum toxin are 4 indications for surgery: (1) airway obstruc- injection be used for recalcitrant granuloma tion, (2) to rule out carcinoma (in selected cases), cases.34 We have used this treatment and found it (3) when the granuloma matures and becomes a to be effective in selected cases. It is, however, fibroepithelial polyp, and (4), on rare occasions, to still important to attempt to identify each of the restore the voice in a patient who needs prompt underlying etiologies; otherwise, granuloma voice restoration.32 When surgical removal is per- recurrence is likely. For patients who appear to formed, it is important to avoid reinjury to the have chronic abusive behaviors wherein repeated perichondrium. In addition, for granuloma surgery, trauma is believed to be a crucial factor in a recal- we recommend using jet ventilation so that endo- citrant granuloma, we use 15 IU of botulinum tracheal intubation may be avoided. toxin in the ipsilateral thyroarytenoid muscle. We do not use intralesional depo-steroid injec- Others use low-dose (2.5 IU) bilateral injections. tions, because such injection may delay epithelial- We wish to emphasize that the routine use of bot- ization. Once a granuloma is removed, a race is on ulinum toxin injection as a primary treatment is between granulation, which comes from the depths not appropriate. of the wound, and epithelialization, which occurs Otolaryngology– Head and Neck Surgery 342 ZEITELS et al April 2002
from the edges of the wound. Although it has been Hz) because the mass-loaded folds oscillate at an debated whether cold knife versus laser is preferable, inordinately low frequency. Females present more we usually use the laser to excise these relatively frequently than do men and undergo phonomicro- vascular lesions without any apparent problems. surgical management more frequently because of Within the past decade, we have identified a num- the greater discrepancy from their normal funda- ber of patients with recurrent vocal process granulo- mental frequency (180 to 230 Hz). mas that have underlying vocal fold paresis. In some Typically, Reinke’s edema presents as extensive of these cases, unilateral and/or bilateral medializa- swelling that is situated on the superior surface of tion laryngoplasty has been carried out with a suc- the musculomembranous vocal fold. It has a multi- cessful resolution of the granulomas.36 In one factorial genesis; these patients typically smoke notable case, the patient had had granulomas extensively, have laryngopharyngeal reflux, and removed 7 times over a 3-year period. We performed demonstrate vocal hyperfunction.42 Hypo- bilateral medialization laryngoplasty for bilateral thyroidism must also be ruled out. The swelling vocal fold paresis 5 years ago, and there has been no probably occurs from the increased aerodynamic recurrence of granuloma since that time. pressures that drive vocal fold mucosal oscillation In summary, arytenoid granulomas are com- in a general environment of glottal mucositis, mon, have a multifactorial pathogenesis, and which is secondary to smoking and reflux. The often are recalcitrant to therapy. Identification swelling is typically bilateral but often asymmetric and management of each of the underlying fac- in volume. Airway symptoms are unusual if the tors are important to achieve successful treatment arytenoids abduct normally, because the edema is outcomes. confined to the anterior glottal aperture. Epithelial pliability and mucosal wave characteristics vary REINKE’S EDEMA greatly between patients and are dependent on the Background viscoelasticity of the pathologic SLP. Some indi- Reinke37,38 described the potential space that viduals have hyperdynamic pliable waves, and oth- bears his name in 1895. Its anteroposterior bound- ers, who have sustained severe phonotrauma, aries are the anterior commissure tendon and ary- demonstrate poor pliability and mass motion of the tenoid vocal process, whereas the vocal ligament is epithelium and pathologic SLP. When the edema is deep to Reinke’s space. Hirano39 referred to this extensive, it can potentially obscure an occult region as the SLP, which is underlying the vibrato- malignancy. ry epithelium. Excessive swelling of this space is known as Reinke’s edema, polypoid corditis, poly- Treatment poid laryngitis, or polypoid degeneration. Treatment of Reinke’s edema begins with elim- Histopathologic analysis of the tissue reveals ination of predisposing risk factors. These individ- that decreased amounts of fibronectin, collagen, uals should discontinue smoking, have their reflux and elastin are evident in the basement membrane controlled, and undergo preoperative vocal therapy and lamina propria. The vocal fold is more before undergoing a procedure.42,43 Systemic deformable.40 Thickening of the epithelial base- steroids are not routinely used to treat Reinke’s ment membrane, edematous lakes, and increased edema, and topical beclomethasone has not been vessel wall thickness are also seen.41 The initiating shown to be effective.44 Patients should be advised trauma leading to the edema is thought to be injury that if they continue to smoke, the problem will not to the capillary endothelium with subsequent resolve without surgery and will likely recur sub- extravasation of fluid into the potential space. sequent to surgical resection.43 Many surgeons will not operate on patients with Reinke’s edema if Clinical Presentation they continue to smoke unless there is concern that Individuals with polypoid corditis describe the cancer may coexist with the polypoid condition. gradual onset of a rough and abnormally low- However, extensive edema may obscure the identi- pitched voice (females, < 130 Hz; males, < 110 fication of an early malignancy in the office, so Otolaryngology– Head and Neck Surgery Volume 126 Number 4 ZEITELS et al 343
that some individuals will undergo earlier micro- fore shortened.49 If leukoplakia/keratosis or another laryngoscopic intervention if keratosis is noted. suspicious process involves the mucosa, that tissue Surgery has been the mainstay of treatment for should also be removed for pathologic examination. Reinke’s edema. Vocal-fold stripping46 was designed This may cause a defect to be present that will as a one-handed, unmagnified treatment for Reinke’s lengthen the healing time. After an initial period of edema by means of a monocular laryngoscope and vocal rest of about 10 days, patients should receive without general anesthesia. Unfortunately, this pro- vocal therapy and be monitored closely. Preventing cedure is imprecise, and frequently, excessive SLP recurrence is dependent on modification of the pre- and epithelium are removed. This can result in a pro- disposing factors, especially smoking. longed period of healing and, often, stiff scarred Control of the medical factors along with surgi- vocal folds. Although the vocal folds appear normal cal resection will usually elevate the fundamental by means of a mirror or fiberoptic examination, stro- frequency of female patients to approximately 150 boscopy reveals loss of epithelial pliability and lack Hz, which is commensurate with the normal fun- of vibration. damental frequency for female smokers.42 Patients In 1985, Hirano et al47 described a more precise should also undergo a course of voice therapy technique that involves incising the epithelium lat- postoperatively because the biomechanics of the eral to the polypoid area, elevating the mucosa as glottal sound production has been radically altered a flap, reducing the gelatinous matrix within the and they have become accustomed to phonating SLP that forms the bulk of the abnormal vocal with excessive subglottal pressure.42 Courey et al50 fold, redraping the flap, and trimming the excess and Zeitels et al42 demonstrated that normal mucosa (Fig 4A to C). A microscissors is used for mucosal waves are rarely restored despite the use the initial incision unless there is prominent subep- of Hirano’s microflap technique. ithelial vascular injection, in which case the CO2 In summary, Reinke’s edema has a multifactori- laser48 can be advantageous. The gelatinous hyper- al genesis and the majority of surgical procedures trophied SLP should then be carefully contoured are performed on women due to the fact that they and reduced to a more normal volume. This can be sustain greater discrepancy from normal phonatory done by suctioning or by direct removal. Great characteristics. Successful management requires care must be taken not to overreduce the SLP, control of risk factors: smoking, phonotrauma, and which results in an inordinately stiff vocal sys- reflux and precise surgical technique. tem.42 The vocal ligament should never be visual- ized directly. Overreduction of the SLP can result UNILATERAL VOCAL FOLD PARALYSIS in a severely strained harsh voice, because these Background individuals already use high subglottal pressures to There is currently a vast array of treatment drive their floppy mass-loaded folds. Vocally, it is options for unilateral vocal fold paralysis (UVFP), preferable to leave a larger fold than to create a although fundamentally these options fall into 1 or visually pleasing smaller fold. more of 4 categories: (1) voice therapy, (2) injec- Once the SLP has been reduced, the epithelium tion laryngoplasty, (3) laryngeal framework is redraped and trimmed appropriately. There are surgery, or (4) reinnervation or pacing. The many varied opinions as to whether both vocal folds treatment options are a testament to the diligence should be worked on simultaneously. Exuberant with which laryngologists, speech pathologists, resection of epithelium and SLP anteromedially and others have pursued rehabilitation of this clin- may leave 2 opposed raw surfaces at the anterior ical problem. They are also a reminder that the commissure, which can lead to web formation. If ideal treatment for UVFP, the ability to reconsti- the incisions and dissection are confined to the tute physiologic vocal fold movement, is not yet superior surface of the vocal folds, bilateral proce- established. dures were not associated with complications.28,42 Advances in recent years have come primarily Microflap cytoreduction avoids removing exces- in the form of refinements or modifications to sive amounts of mucosa, and healing time is there- existing procedures, but there are some notable Otolaryngology– Head and Neck Surgery 344 ZEITELS et al April 2002
examples of truly pioneering investigation. The rect injection laryngoplasty using topical anesthe- following brief review of recent literature is divid- sia on the awake and upright patient with modern ed according to the broad treatment categories stat- video laryngoscopy equipment together with tradi- ed above and focuses on voice restoration. tional injection devices.57-59 Efficiency, cost, avoidance of anesthetic risks, and the ability to Clinical Presentation actively monitor voice in a relatively normal Vocal fold paralysis has been one of the phonatory posture are some of the proposed omnipresent laryngologic management problems advantages of indirect techniques. since the origin of the specialty. Patients present In the canine vocal fold, Stein et al60 explored with varied vocal function and accompanying the histopathologic and migratory properties of 4 aerodynamic dysfunction. This has stimulated a different injectable alternatives for vocal fold large body of literature over the past 140 years that medialization: Teflon (Polytef Paste; Mentor Inc, attempted to explain this variability. At present, the Norwell, MA), autologous fat, silicone suspension, observed inconsistent resting position of the ary- and hydroxylapatite cement. The silicone suspen- tenoid and, in turn, the musculomembranous vocal sion caused the most intense inflammatory fold is believed to be secondary to (1) residual response, whereas Teflon resulted in chronic innervation,51 (2) unpredictable reinnervation and inflammation with detectable regional lymph node synkinesis,52 and (3) atrophy (described in 187253) migration. The authors did not see significant and fibrosis of denervated muscles.54 These factors inflammation with hydroxylapatite or fat, and the also determine the final position, contour, length, fat was preserved at 6 months from injection. mass, and aerodynamic viscoelasticity of the vocal Issues with the persistence of viable fat do remain, fold. however, as Saccogna et al61 found no significant graft survival 12 months after lipoinjection into the Treatment feline vocal fold. Research continues with a vari- Voice therapy. Recent literature continues to ety of injectable substances, such as autologous reflect the fact that laryngologists and speech collagen62 or fascia.63 pathologists believe voice therapy plays a signifi- Laryngeal framework surgery. The type I cant role in the treatment of patients with UVFP. In thyroplasty or medialization thyroplasty, explored particular, many patients with less severe dyspho- in detail originally by Isshiki et al64 has received nia or better glottic closure have favorable out- much attention in recent years. It continues to be comes with voice therapy alone, and preoperative the most commonly used laryngeal framework or postoperative voice therapy can help facilitate procedure and most frequent intervention for para- voice recovery in more severely dysphonic lytic dysphonia. Implant composition, develop- patients who are treated surgically.55 Indeed, ment of standardized kits, pediatric application, Isshiki56 recently said that “Phonosurgery some- and treatment outcomes were some of the areas of times works as pump-priming to facilitate the recent interest. voice therapy that follows.” Cummings et al65 designed the VoCom System Injection laryngoplasty. Although recent (Smith and Nephew Richards, Memphis, TN), clinical trends reflect that there is an increasing use which uses preformed hydroxylapatite prostheses of laryngeal framework surgery over injection for medialization of the musculomembranous techniques for treating UVFP, there continues to region of the vocal fold, and Montgomery et al66 be a role for injectable implants in the temporary developed the Montgomery Thyroplasty Implant and permanent less common treatment of this System (Boston Medical Products, Westborough, problem. Both the technique of injection and the MA) with preformed wedge-shaped Silastic pros- nature of the injected material have received atten- theses.66 Limited tissue reactivity and implant sta- tion in current literature. bility are proposed features of the VoCom Several authors have demonstrated the value of System,67 whereas the Montgomery implant was blending the old with the new by performing indi- specifically designed with an extended posterior Otolaryngology– Head and Neck Surgery Volume 126 Number 4 ZEITELS et al 345
flange to medialize the vocal process of the ary- arytenoid adduction and concluded that it medial- tenoid cartilage. ized and lowered the vocal process of the arytenoid A bioimplant with a long history of use in car- but did not increase vocal fold stiffness in the mid- diovascular surgery, expanded polytetrafluoroeth- dle musculomembranous region. In keeping with ylene (ePTFE [Gore-Tex]; W.L. Gore & this finding, most recent literature has primarily Associates, Inc, Flagstaff, AZ) has also been used discussed the use of arytenoid adduction in con- in medialization thyroplasty68,69 and was recently junction with other procedures such as media- described in conjunction with arytenoid adduc- lization thyroplasty that act more on the tion.69,70 These groups describe favorable voice musculomembranous vocal fold.69,70,77,78 Indeed, results, a straightforward surgical technique, and it has become commonplace in the literature to the safety of an implant material that has stood the refer to an anterior subunit consisting of the mus- test of time in other surgical disciplines. culomembranous vocal fold and a posterior sub- Recently, type I thyroplasty was reported in the unit consisting of the arytenoid cartilage and pediatric population,71 and it was indicated that attached muscles. standard methods for determining the vocal fold Citing the fact that arytenoid adduction does not level and window placement in adults were not simulate the synchronous agonist-antagonist func- accurate in children. These authors found that tion of each of the intrinsic laryngeal muscles, implants were frequently placed too high if adult Zeitels69 introduced the adduction arytenopexy as guidelines were used, and they suggested an intra- a new procedure effecting favorable arytenoid operative method for determining vocal fold level position in UVFP. This operation involves opening using visualization of needles passed through the the lateral aspect of the cricoarytenoid joint and thyroid ala. They concluded that pediatric type I manually medializing the arytenoid on the cricoid thyroplasty is an evolving procedure. facet. The arytenoid cartilage is thus drawn poste- Using aerodynamic and acoustical data, Lundy riorly, superiorly, and medially and is fixed pre- et al72 compared short- versus long-term voice cisely with a suture. The authors combine this results with type I thyroplasty. Although preopera- procedure with medialization thyroplasty to tive versus postoperative data showed significant address both anterior and posterior subunits and differences, they found no statistically significant more recently have incorporated cricothyroid joint differences between the 1-month versus the >1- subluxation as an adjunctive procedure.69,79 The year postoperative assessment points. A validated cricothyroid subluxation procedure is the sole sta- voice outcomes tool, the Voice-Related Quality of tic reconstructive procedure for UVFP that is pri- Life measure was also recently used to assess out- marily designed to adjust for tension in the comes with the type I thyroplasty. Dramatic differ- denervated musculature, which has a different res- ences in Voice-Related Quality of Life were seen onant frequency for optimal vibration. With this when patients with untreated UVFP were com- innovation, most patients will obtain 2 octaves of pared with patients who had undergone a type I dynamic frequency range.79 Woodson et al80 also thyroplasty.73 A survey conducted by Rosen74 appreciated the importance of agonist-antagonist struck a cautionary note about the surgical learning muscle activity in arytenoid position and noted curve, as major complications were more frequent improvement in arytenoid posture after arytenoid for surgeons who had performed <10 procedures adduction, which included a supplemental posteri- in their career. orly oriented anchoring suture. Surgical manipulation of the arytenoid cartilage Laryngeal reinnervation or pacing. The itself is likely the second most commonly per- quest for methods to functionally reinnervate the formed laryngeal framework procedure. Originally paralyzed larynx continues. Nerve transfer proce- described by Isshiki et al,75 many authors favor dures are currently the most widely used reinner- arytenoid adduction for closing large posterior vation operations, although reinnervation in glottal gaps. Noordzij et al76 used an excised general is much less commonly used than laryn- canine larynx model to study the biomechanics of geal framework surgery. Otolaryngology– Head and Neck Surgery 346 ZEITELS et al April 2002
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