Voice Changes after Treatment for Bilateral Vocal Fold Motion Impairment Betty S. Tsai, MD Mark S. Courey, MD Sarah L. Schneider, MS, CCC-SLP Soha Al-Jurf, MS, CCC-SLP UCSF Department of Otolaryngology - Head and Neck Surgery October 17, 2008 Vocal Fold Motion Impairment Abnormal adduction and/or abduction of the vocal folds Neurologic Definition of paralysis -- loss or impairment of motor function in a part due to a lesion of the neural or muscular mechanism (Dorland s Medical Dictionary) Structural Examples include fixation of cricoarytenoid joint and posterior glottic stenosis. Etiology of Bilateral Vocal Fold Immobility Surgical options For medialized vocal cords Suture lateralization Arytenoidopexy Posterior cordotomy Arytenoidectomy Tracheotomy From Laryngoscope 108(9) 1346-1350 - Changing Etiology of Vocal Fold Immobility 1
Surgical options For lateralized cords Injection thyroplasty Medialization thyroplasty Aim To critically analyze the voice outcomes and airflow after surgical intervention for bilateral vocal fold motion impairment All patients evaluated at the UCSF Voice and Swallow Center between 2004 and 2008 Airway Evaluation: PFTs Flow volume loops Decreased forced inspiratory flow (FIF) Flattened inspiratory curve Peak inspiratory flow PIF < 1.5 L/s threshold for moderate activity (Kashima 1991) PIF < 1.0 L/s critical Voice Rating System GRBAS scale (Hirano) Grade (overall severity of dysphonia) Roughness Breathiness Asthenia Strain Karnell et al (2006) very good reliability between clinicians on the GRBAS scale (r > 0.80) 2
Patients Pt Etiology Trach Surgical intervention 1 Esophageal adenoca no Suture lateralization with arytenoidopexy 2 idiopathic no cordotomy 3 Guillain-Barre no Suture lateralization with arytenoidopexy 4 Age-related cricoarytenoid fixation 5 RLN injury from parathyroid exploration yes yes Cordotomy with partial arytenoidectomy (with revision) Cordectomy with suture lateralization 6 s/p total thyroidectomy yes Revision cordotomy and partial 7 s/p total thyroidectomy yes Partial cordectomy with suture lateralization 8 idiopathic no Bilateral thyroplasty 9 Esophageal adenoca no Laser cordotomy Airway changes 7 patients with PFT data Patient Preop PIF Postop PIF PIF improvement 1 > 2 L/s NA 2 1.5 L/s 1.75 L/s 0.25 L/s (17%) 3 0.75 L/s 1.36 L/s 0.61 L/s (81%) 5** 0.8 L/s 1.5 L/s 0.7 L/s (88%) 6* 1.2 L/s 1.7 L/s 0.5 L/s (42%) 7* > 2 L/s NA 9 1.5 L/s 1.7 L/s 0.2 L/s (13%) * Decannulated ** Decannulated but re-trached 1 year later p = 0.01 Airway improvement Sample voices ¾ of patients with a trach were decannulated after their vocal cord surgery (cordectomy with suture lateralization or partial arytenoidectomy) One patient had baseline OSA and could not be decannulated One patient was decannulated but re-trached about 1 year later when she had reexploration of her parathyroids. Suture lateralization with arytenoidopexy 3
Sample voices Cordotomy Sample voices Bilateral thyroplasty Voice outcomes Grade 1 Suture lateralization with arytenoidopexy 3 3 2 cordotomy 1.25 0.75 3 Suture lateralization with arytenoidopexy 1 2.75 1.75 2.75 5 Cordectomy with suture lateralization 2.5 3 2.25 1.25 7 Partial cordectomy with suture lateralization 2.25 2.5 8 Bilateral thyroplasty 2.5 0.5 9 Laser cordotomy 1.25 2.25 Roughness 1 Suture lateralization with arytenoidopexy 1.25 1.25 2 cordotomy 1 0.25 3 Suture lateralization with arytenoidopexy 1 0.25 1 2 5 Cordectomy with suture lateralization 2 0.25 0.25 0.25 7 Partial cordectomy with suture lateralization 2.25 0.5 8 Bilateral thyroplasty 1.75 0.25 9 Laser cordotomy 1 0.5 4
Breathiness 1 Suture lateralization with arytenoidopexy 3 2.75 2 cordotomy 0 1 3 Suture lateralization with arytenoidopexy 0 1.75 0 2 5 Cordectomy with suture lateralization 1 3 2 1 7 Partial cordectomy with suture lateralization 0 2.75 8 Bilateral thyroplasty 2.25 0.75 9 Laser cordotomy 0.75 2 Asthenia 1 Suture lateralization with arytenoidopexy 3 2.75 2 cordotomy 0 0.25 3 Suture lateralization with arytenoidopexy 0 2.5 0 1.25 5 Cordectomy with suture lateralization 1 3 1.5 1 7 Partial cordectomy with suture lateralization 0.5 2.25 8 Bilateral thyroplasty 1.75 0 9 Laser cordotomy 1 2.25 Strain 1 Suture lateralization with arytenoidopexy 1.25 2 2 cordotomy 0.75 1 3 Suture lateralization with arytenoidopexy 0.5 3 1.5 1.5 5 Cordectomy with suture lateralization 2.75 2.5 2.25 0.5 7 Partial cordectomy with suture lateralization 1.25 1.75 8 Bilateral thyroplasty 0.5 0.75 9 Laser cordotomy 1.25 1.5 Analysis of voice outcomes In the 8/9 patients who had medialized cords and underwent procedures to increase their airway: Variable Avg Preop Avg Postop Change P-value G 1.91 2.28 + 0.37 0.27 R 1.22 0.66-0.56 0.13 B 0.84 1.03 + 0.19 0.03* A 0.88 1.91 + 1.03 0.03* S 1.44 1.71 + 0.27 0.52 5
Summary of Results - Airway The improvement in peak inspiratory flow after surgery was statistically significant. Some but not all patients with tracheotomies can be decannulated. Patients who were successfully decannulated met the minimum threshold requirement of 1.5 L/s. Summary of Results - Voice While there is little change in the grade of the voice, the breathiness and asthenic qualities increased with statistical significance. The amount of strain varied widely between patients with similar surgeries. Conclusions There exists a fine balance between optimum airway and voice in patients with bilateral vocal fold paralysis who are considering surgery. A statistically significant improvement in airway can be obtained at the price of increased breathiness and asthenia of the voice without a significant change in grade. 6