Pavan S. Mallur

Vocal Fold Injection: Review of Indications, Techniques, and Materials for Augmentation

Vocal fold injection is a procedure that has over a 100 year history but was rarely done as short as 20 years ago. A renaissance has occurred with respect to vocal fold injection due to new technologies (visualization and materials) and new injection approaches. Awake, un-sedated vocal fold injection offers many distinct advantages for the treatment of glottal insufficiency (vocal fold paralysis, vocal fold paresis, vocal fold atrophy and vocal fold scar). A review of materials available and different vocal fold injection approaches is performed. A comparison of vocal fold injection to laryngeal framework surgery is also undertaken. With proper patient and material selection, vocal fold injection now plays a major role in the treatment of many patients with dysphonia.

Quantification of benign lesion regression as a function of 532-nm pulsed potassium titanyl phosphate laser parameter selection.

Although the potassium titanyl phosphate (KTP) laser is versatile, the variability in laser parameters for laryngeal pathologies and the lack of clinical efficacy data remain problematic. We provide preliminary data regarding these parameters for benign lesion regression. In addition, we describe a novel method for the quantification of the effects of the KTP laser on vocal fold (VF) lesions.

Preoperative and Postoperative Intracranial Complications of Acute Mastoiditis

Objectives: We determined the clinical characteristics and treatment outcomes of an unusual cluster of intracranial complications seen in acute mastoiditis (AM). Methods: We performed a retrospective review of pediatric patients treated for AM in a tertiary care hospital from March 2006 to March 2007. Results: Eleven children, 6 months to 10 years of age (mean age, 3.8 years), were treated for AM confirmed by computed tomography, which identified asymptomatic intracranial complications in 8 of the 11 patients: These were sigmoid sinus thrombosis (4 patients), epidural abscess (4), perisigmoid abscess or bony erosion (2), and tegmen mastoideum dehiscence (1). All patients required operative intervention with tympanomastoidectomy, although only 2 patients required neurosurgical intervention, consisting of evacuation of epidural abscess and sigmoid sinus thrombosis, respectively. Cultures yielded routine organisms and 1 multidrug-resistant strain of Streptococcus pneumoniae. One patient developed reaccumulation of the subperiosteal abscess that required revision mastoidectomy, and another patient developed postoperative sigmoid sinus thrombosis. Conclusions: Although uncommon, intracranial complications of AM may present without clinical signs or symptoms. Computed tomography of the temporal bone with contrast is essential for identifying asymptomatic complications. Mastoidectomy remains the mainstay of surgical treatment. Neurosurgical intervention and anticoagulation may be avoided with protracted postoperative intravenous antibiotics. Postoperative vigilance is crucial, as complications may evolve despite aggressive therapy.

Safety and efficacy of carboxymethylcellulose in the treatment of glottic insufficiency.

No studies to date have examined the clinical safety and efficacy of carboxymethylcellulose (CMC) for vocal fold injection. The current study investigates the voice outcomes and complications of CMC injection.

Office-Based Laryngeal Injections

Office-based vocal fold injection (VFI), though initially described more than a century ago, has recently reemerged as an attractive alternative to VFI performed during microsuspension laryngoscopy. Multiple office-based approaches exist, including percutaneous, peroral, and transnasal endoscopic approaches. Surgeon preference typically dictates the approach, although patient tolerance or anatomic variations are also key factors. Regardless of the approach or indication, a myriad of technical considerations make preparation and familiarity requisite for optimal patient outcomes. Office-based VFI offers several distinct advantages over traditional direct or microsuspension laryngoscopy VFI, making it a standard of treatment for a variety of indications.

Proposed classification system for reporting 532‐nm pulsed potassium titanyl phosphate laser treatment effects on vocal fold lesions

Currently, no standard exists for reporting treatment results for the potassium titanyl phosphate (KTP) laser. The goal of this study was to establish a validated classification schema for reporting immediate tissue effects after laser treatment.

A model for 532‐nanometer pulsed potassium titanyl phosphate (KTP) laser—Induced injury in the rat larynx

The potassium titanyl phosphate (KTP) laser is emerging as a potentially effective treatment for various vocal fold pathologies. To date, the precise mechanism(s) of action of this wavelength on the layered microarchitecture of the vocal fold remains unknown. The purpose of this study is to develop an in vivo model for the use of the KTP laser in the rat vocal fold and to characterize the potential of this model for future studies.

Voice Outcomes following the Gray Minithyrotomy

Objectives: Most practitioners have limited treatment options for vocal fold scar and sulcus vocalis. The Gray minithyrotomy (GMT) is a surgical procedure for the treatment of these conditions, although limited objective data exist regarding voice outcomes. This study compares the quantified subjective and visual perceptual outcomes following GMT for the treatment of vocal fold scar and sulcus vocalis. Methods: We performed a retrospective review of patients who underwent GMT in a single institution. Patient-reported satisfaction, Voice Handicap Index–10 scores, results of video perceptual analysis, and complications were recorded. Results: Sixteen patients underwent GMT for phonotraumatic or postoperative scar (11), radiation-induced scar (3), or sulcus vocalis (2). Seven underwent bilateral operations. Follow-up data were available for 12 patients. Eight patients had 2 or more failed surgical interventions before GMT. Seven of the 13 procedures resulted in a self-reported improvement. Although the mean preoperative Voice Handicap Index–10 score (30.6) across all patients did not decrease after the operation, 6 of the 13 GMT procedures resulted in improvement (mean decrease, 7.5). Complications, encountered in 5 patients, included ecchymosis, neck abscess, tongue numbness, wound dehiscence, and aspiration pneumonia. Conclusions: The GMT is a viable treatment for severe vocal fold scar and sulcus vocalis. Our results show improvement in half of a cohort that was marked by previous failures at improving voice. These results point to the recalcitrant nature of voice difficulties in treating vocal fold scar and sulcus, and may properly guide clinicians and patients in their expectations following this infrequently used technique.

532-nanometer potassium titanyl phosphate (KTP) laser-induced expression of selective matrix metalloproteinases (MMP) in the rat larynx†‡§

The 532‐nm KTP laser is clinically useful to induce benign vocal fold lesion regression without a fibrotic response. Previously, we described an in vivo model for KTP‐induced injury in the rat larynx. This study uses this model to correlate the KTP‐induced histologic and biochemical changes with the absence of long‐term vocal fold fibrosis seen in clinical scenarios.

Analysis of Potassium Titanyl Phosphate Laser Settings and Voice Outcomes in the Treatment of Reinke's Edema.

Objective: Despite increased clinical utility of the 532-nm potassium titanyl phosphate (KTP) laser, no studies have examined outcomes for Reinke’s edema (RE) as a function of laser parameters and initial treatment effects. Variability in delivery parameters, fiber-to-tissue distance, and immediate end-tissue effects limits universal application of existing study outcomes. We examine voice outcomes using standardized treatment classification, providing justification for laser parameter selection and immediate tissue effect in clinical use. Methods: Retrospective review of 9 patients who underwent KTP laser treatment for RE. Demographics, RE severity, laser settings, total laser energy, and immediate tissue effects were correlated with quantified voice outcomes. Results: An average of 157 joules (6-640 J) was delivered over a 0.369-second exposure time (0.1-0.9 seconds). Immediate tissue effects varied from nonablative treatment (type I and type II) to ablation without tissue removal (type III). Overall, Voice Handicap Index-10 (VHI-10) decreased by 8.23; improvement was most pronounced with type II treatments (delta VHI-10 = 12). No complications were encountered. Conclusion: Potassium titanyl phosphate laser can be safely and effectively used to improve voice in RE patients regardless of severity. This is the first study to provide detailed information on laser settings, energy delivery, and treatment effect in RE management; these results may guide clinical use of this modality, especially for novice laser surgeons.