The Effects of the Newest Palatopharyngeal Surgery (Barbed Pharyngoplasty) on Voice Quality (2023)

Silk-Hyaluronic Acid (Silk-HA) is a novel vocal fold augmentation material that has been used in humans since July 2020. There is a paucity of published data on Silk-HA and its longevity remains a question. This study aimed to evaluate a single surgeon's initial experience performing Silk-HA injection laryngoplasty for the treatment of glottic insufficiency.

Retrospective chart review of Silk-HA injections between July 2020 and December 2021. Subject demographics, diagnoses, volume of material injected, VHI-10 data, and complications were collected. A blinded perceptual voice analysis of voice samples was performed by two voice-specialized speech-language pathologists (SLP) for a subset of unilateral vocal fold paralysis patients before and 3-months following silk-HA injection. Univariate assessment of the change in VHI-10 and perceptual voice analyses at 3-month follow up was determined.

58 patients (43.1% female) underwent Silk-HA injection with a mean age of 64 (range 21-88). 38 subjects had unilateral paralysis (65.6%), and the remaining had scar, atrophy, paresis or a combination thereof. 49 injections were unilateral (84.5%). Mean volume of silk injected was 0.26 mL. Complications were rare, most notable though for 2 admissions for dyspnea and laryngoscopic evidence of hemi-laryngeal edema (3.4%). Mean change in CAPE-V overall severity rating was -32.9 (P<0.0001), and VHI-10 was -14.6 ± 10 (P=0.0013). 14 patients underwent a repeat silk-HA injection for ongoing glottic insufficiency (loss of augmentation vs under-augmentation).

Preliminary results for Silk-HA show potential for ongoing improvement of glottic insufficiency at 3 months from date of augmentation. Clinician and patient perception of voice outcomes showed overall improvement at three months, though longevity remains to be determined. While overall well tolerated and without serious complications in 96% of the cohort, patients should be counseled on the potential for airway edema and symptomatic dyspnea requiring steroid management and observation.

Subglottic stenosis (SGS) is characterized by a narrowing of the trachea near the cricotracheal junction and impairs breathing. SGS may also adversely affect voice quality, but for reasons that are not fully understood. The purpose of this study is to provide experiment-based data concerning the effects on phonation of airway obstruction due to SGS.

Basic science

A device simulating a SGS of adjustable severity ranging from 36% to 99.8% obstruction was created. Self-oscillating synthetic VF models were mounted downstream of the device and data were acquired to evaluate the effects of the obstruction on phonatory response.

Onset pressures were relatively insensitive to obstructions of up to approximately 80% to 90% reductions in subglottic airway area and sharply increased thereafter. Flow rate (under conditions of constant pressure), flow resistance, and fundamental frequency all exhibited similar degrees of sensitivity to SGS obstruction as onset pressure. High-frequency noise became significant by 80% obstruction. Glottal area appeared to be less sensitive, not being affected until approximately 90% obstruction.

Consistent with previous computational studies, this study found that aerodynamic, acoustic, and vibratory responses of self-oscillating VF models were largely unaffected by SGS until approximately 80% to 90% obstruction, and significantly affected at higher obstructions. This suggests that Grades I and II stenoses are unlikely to introduce subglottic airway aerodynamic disturbances that are sufficient in and of themselves to significantly alter phonatory output. The SGS model introduces a framework for future benchtop studies involving subglottic and supraglottic airway constrictions.

This study aimed to investigate the possible vocal impact confirmed by diagnostic tests, the degree of perception of possible vocal impairment by patients with Unilateral Diaphragmatic paralysis (UDP) and its correlation with ventilatory weakness.

The researchers conducted an analytical, observational and case-control study with 70 individuals, including 35 UDP patients and 35 healthy patients in a control group, who underwent the following assessments: 1) Self-assessment of voice handicap (VHI-10); 2) Self-Assessment of Quality of Life (SF-36); 3) Self-Assessment of Dyspnea (MRC); 4) Objective vocal measures (Maximum Phonation Time (MPT) in /a/, /s/, /z/ and glottal-to-noise excitation ratio); 5) Functional respiratory pressures (Spirometry and maximum ventilatory pressures); 6) General degree of dysphonia – G on the GRBAS Scale. The sex, age and body mass index (BMI) of the individuals were the variables used to match the sample of this study.

When compared with controls, patients with UDP had a restrictive functional pattern and inspiratory weakness, with symptoms of dyspnea and worsening quality of life. When associated with a possible vocal impact, these patients had voice handicap and decreased MPT values for all phonemes, especially /a/. There was also a correlation between vocal performance and inspiratory weakness. However, it should be noted that, despite having vocal impairment, many patients did not report the perception of this fact, somehow neglecting such impairment.

In addition to the expected weakness of the ventilatory muscles, patients with UDP had clinically verified vocal impact, and those who had greater inspiratory weakness also had greater voice impairment. Finally, it is relevant that not all patients perceived such vocal impact, which showed a very reduced perception of this impairment in patients with UDP.

Injectable laryngoplasty with hydroxyapatite and hyaluronic acid is frequently used for the treatment of glottic incompetence. The effectiveness of these substances is controversial due to the heterogeneity of studies.

To evaluate the effectiveness of the treatment for glottic incompetence using hydroxyapatite and hyaluronic acid.

Systematic review and meta-analysis.

MEDLINE, PUBMED, LILACS, SCOPUS, EMBASE, Cochrane, clinicaltrials.gov, published and unpublished trials, Web of Science.

Studies that evaluated vocal fold function before and after 4-6 weeks and 6 months of hydroxyapatite and hyaluronic acid injection in adults with glottic incompetence. Exclusion criteria: studies with outcome, follow-up time or type of intervention outside the predetermined pattern or systematic review and meta-analysis.

Primary outcome - Maximum Phonation Time. Secondary outcomes - Voice Handicap Index (VHI)-30, Parameters G and B of GRBAS Scale. Outcomes were analyzed for mean differences with the corresponding 95% CI.

Six hundred forty-four studies identified, 12 included (5 CaHA; 6 HA; 1 HA and CaHA). After 4-6 weeks the mean difference were: MPT (+5.86), IDV (-39.32), G (-1.14), and B (-1.46). After 6 months: MPT (+5.97), IDV (-30.13), G (-1.33), and B (-1.33).

Studies comparing injectable drugs are small, as well as the number of patients in each one, making the isolated comparison of substances difficult.

There is an evidence that the injectable substances HA and CaHA are effective in the treatment of glottic incompetence, however, it is important that more studies are carried out comparing the two substances.