Vocal Fold Fat Augmentation for Atrophy, Scarring, and Unilateral Paralysis: Long-term Functional Outcomes

Objective There is a debate regarding the durability of fat implants. Our experience and recent publications suggest fat implantation may deliver a long-lasting improvement. This study aims to present the long-term outcomes for vocal fold fat augmentation using strict harvesting, preparing, and implantation protocols. Study Design A prospective cohort conducted between 2014 and 2020 (recruitment 2014-2017). Setting An academic tertiary referral center. Subjects and Methods Twenty-two patients with glottic insufficiency were enrolled: 11 had unilateral vocal fold paralysis (UVFP), and 11 had atrophy or scar. Harvested fat was injected unilaterally or bilaterally into multiple sites. Six of these patients also had simultaneous microlaryngoscopic removal of other benign glottic lesions. Outcome measurements included video stroboscopy; Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) score; Voice Handicap Index (VHI); and acoustic analysis, performed preoperatively, 3, 12, 24, and 36 months after surgery. Results Ten augmentations were unilateral and 12 bilateral. Comparing the preoperative and 36-month postoperative periods, the mean VHI score improved from 73.45 (±22.78) to 44.88 (±28.93), P = .001, and the mean GRBAS decreased from 8.64 (±3.89) to 2.82 (±2.3), P = .001; 24 months postoperatively, the mean fundamental frequency decreased from 163.88 Hz (±41.61) to 150.44 Hz (±41.47), P = .012. Stroboscopic analysis revealed statistically significant improvement in mucosal wave propagation, phase closure, and phase symmetry. Best results were achieved in the UVFP subgroup. Computed tomography scans demonstrated long-term viability of the implanted adipose tissue. Conclusion Fat is an excellent source of autologous graft. With careful patient selection and proper surgical technique, fat is suitable for long-term correction of glottic insufficiency. Fat augmentation should be considered as a long-lasting or even permanent solution, rather than temporary.

Augmentation of Scarred Vocal Folds With Centrifuged and Emulsified Autologous Fat Grafts

Objective To review the results of a series of patients with glottic insufficiency caused by scarred vocal folds who underwent injection laryngoplasty with centrifuged and emulsified autologous fat. Study Design Prospective cohort. Setting Single center, tertiary institution. Subjects and Methods Examination of the medical records of 21 patients operated on through injection laryngoplasty with fat grafts for the treatment of dysphonia was performed. All patients were operated on between January of 2015 and September of 2019. The voice variables measured were the GRABS (Grade, Roughness, Breathiness, Asthenia, Strain) scale, the Voice Handicap Index–10 (VHI-10), maximum phonation time, jitter, shimmer, and harmonic/noise ratio before surgery and 8 months later. Results Twenty-six injection laryngoplasties were performed in 21 patients during the reviewed period. Seventeen were men, and 4 were women. Mean age was 57.2 (range, 18-80) years. Mean (SD) follow-up time was 20.7 (9.3) months. Etiology of dysphonia was scarring after tumor resection in 17 patients and sulcus vocalis in 4. Five patients received an additional injection laryngoplasty. Statistically significant improvements were observed in all the parameters evaluated ( P < .05). Conclusions Injection laryngoplasty with fat grafts processed through centrifugation and emulsification is an effective technique for the treatment of dysphonia caused by glottic insufficiency related to scarred vocal folds, with minimal complication rates.

Laryngeal Electromyography-Guided Hyaluronic Acid Vocal Fold Injections for Glottic Insufficiency

Objectives: To assess voice outcomes using the novel technique of in-office laryngeal electromyography-guided vocal fold injections (LEVFI) with hyaluronic acid to treat glottal insufficiency. Secondary objectives included determining the complication/completion rates and if any factors were associated with improved voice outcomes. Methods: Retrospective review of patients who received their first LEVFI from August 2017 to December 2018. Three- and six-month voice outcomes were assessed. Outcomes included voice handicap index-10 (VHI-10), maximum phonation time (MPT), perceptual analysis of voice (GRBAS), fundamental frequency, and stroboscopy. Results: Of the 121 eligible patients (55.4% male, age 63.7 years), 94 (77.7%) had complete 3-month data and 59 (48.8%) had complete 6-month data. VHI-10 was significantly improved from 25.7 ± 7.5 to 20.9 ± 10.9 at 3 months ( P < .001) and to 19.1 ± 11.5 at 6 months ( P < .001). MPT improved from 6.2 ± 5.4 seconds to 9.4 ± 7.1 seconds at 3 months ( P < .001) and to 11.3 ± 8.2 seconds at 6 months ( P < .001). GRBAS was improved in 74.8% of patients ([65.2, 82.8] 95% CI) at 3 months and 80.8% ([69.9, 89.1]) 95% CI) at 6 months. Stroboscopy showed a glottic gap improvement in 74.8% of patients ([65.8, 82.4] 95% CI) at 3 months and in 80.3% ([65.9, 88.5] 95% CI) at 6 months. Fundamental frequency was unchanged, as expected. Multivariate analysis reported that no factors were associated with better voice outcomes. Overall, 177/181 (97.8%) injections were completed. There were no complications. Conclusion: In-office LEVFI is an effective, novel technique to treat glottic insufficiency with improved voice outcomes, high completion rate, and no significant complications.

4290 Acoustic screening for the “wet voice” in a canine laryngeal model

OBJECTIVES/GOALS: Early dysphagia detection reduces risk of pulmonary complications, length of hospital stay, and overall healthcare costs. The biggest limitation for early detection has been the lack of a sensitive, reliable, and noninvasive screening tool. The bedside swallow examination may miss silent aspiration in up to 40% of patients. The objective of this study is to evaluate if acoustic parameters can distinguish normal and wet voice in a canine laryngeal model. Ultimately, our goal is to establish whether the sensitivity of the bedside swallow examination can be augmented with the addition of an acoustic screen in humans. METHODS/STUDY POPULATION: Two excised canine larynges were used for laryngeal phonation simulations under six different conditions over 48 hours. Acoustic recordings were obtained while the larynges were in vibration at the phonation threshold pressure. Phonation was recorded under dry conditions and when the laryngeal introitius was covered with low viscosity glycerin (9.5cP) or high viscosity glycerin (950cP), as well as in adducted and abducted conditions. The latter mimics glottic insufficiency seen in presbylarynx or vocal fold paralysis. RESULTS/ANTICIPATED RESULTS: A total of 112 voice samples were generated and analyzed for pitch, sound pressure level (SPL), % shimmer, % jitter, relative average perturbation (RAP), and noise-to-harmonics using PRAAT software. A multivariate regression model showed that pitch, SPL, % shimmer, % jitter and RAP could significantly predict wetness in abducted conditions only. Could you please add numbers and p values? DISCUSSION/SIGNIFICANCE OF IMPACT: This pilot study indicates that classic acoustic perturbation measures distinguish the dry from the wet larynx only in glottic insufficiency condition in an ex vivo canine laryngeal model. Our next step is to study whether non-linear time series analysis and machine learning can differentiate dry and wet phonation in both adducted and abducted conditions in our animal model. CONFLICT OF INTEREST DESCRIPTION: Dr. Anais Rameau is a co-founder and Chief Executive Officer of MyophonX, a wearable device used to restore speech in patients with limited phonation capacity.

Voice outcome after vocal fold injection augmentation with carboxymethyl cellulose versus calcium hydroxyapatite

BackgroundVocal fold injection augmentation is a recognised treatment modality for glottic insufficiency. Causes of glottal closure insufficiency include vocal fold paralysis, paresis, atrophy, sulcus vocalis, scarring and vocal fold deficiency after laryngeal surgery. A variety of materials exist for injection augmentation. This study aimed to compare voice improvement after injection augmentation between two injectable materials: carboxymethyl cellulose and calcium hydroxyapatite.MethodThis retrospective study included 66 consecutive patients with glottic insufficiency who underwent injection augmentation.ResultsAmong the patients who received their first injection augmentation with carboxymethyl cellulose and their second injection augmentation with calcium hydroxyapatite (n = 28), voice quality improved significantly after both injection augmentations. No significant differences were observed in any of the objective and subjective voice quality measurements examined following carboxymethyl cellulose and calcium hydroxyapatite injections.ConclusionVoice improvement after injection augmentation depends mainly on the improvement of glottic closure, rather than the injection material.