|Year : 2019 | Volume
| Issue : 1 | Page : 15-19
Phonatory outcome of autologous fat injection in unilateral vocal cord palsy
Sachin Gandhi1, Shashank Gupta2, Nilanjan Bhowmick1, Nagaraj Maradi2, Vrushali Desai2
1 Department of ENT; Department of Laryngology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
2 Department of Laryngology, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India
|Date of Submission||07-Jan-2020|
|Date of Acceptance||13-Mar-2020|
|Date of Web Publication||14-May-2020|
Dr. Shashank Gupta
Department of Laryngology, Deenanath Mangeshkar Hospital, Erandwane, Pune - 411 004, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: Evaluate the outcome of autologous fat injection (AFI) in the management of unilateral vocal cord palsy (UVCP). Materials and Methods: In this retrospective study, we obtained data of all patients with UVCP of at least 6 months duration who underwent AFI. Preoperative and postoperative grade, roughness, breathiness, asthenia, and strain (GRBAS), voice handicap index (VHI), and multidimensional voice program scores were obtained and compared to evaluate the subjective and objective outcomes of AFI. Results: Sixty patients underwent AFI. There was significant improvement in perceptual voice, as graded by both – patient and observer, using VHI and GRBAS scale. Significant improvement was also seen in Jitter and Soft Phonation Index on voice analysis. Conclusion: AFI is a simple, safe, and cost-effective method with excellent phonatory outcomes for the management of UVCP.
Keywords: Fat augmentation, laryngoplasty, medialization, vocal cord palsy
|How to cite this article:|
Gandhi S, Gupta S, Bhowmick N, Maradi N, Desai V. Phonatory outcome of autologous fat injection in unilateral vocal cord palsy. J Laryngol Voice 2019;9:15-9
| Introduction|| |
Unilateral vocal cord palsy (UVCP) is a commonly encountered condition at a dedicated voice and airway center. Lack of cord movement leads to inadequate glottic closure which in turn leads to a breathy voice. Along with dysphonia, patients may present with complaints related to aspiration.
Etiology of UVCP is varied. Idiopathic paralysis continues to be the major and elusive cause. Thyroidectomy is the single most common surgical procedure responsible for UVCP. Other causes include cardiac surgery, trauma, and cerebrovascular accidents.
Management options for UVCP include open type 1 medialization thyroplasty, arytenoid adduction, injection laryngoplasty, reinnervation, or a combination of these techniques.
Injection laryngoplasty has proven to be effective and shown to yield stable voice function and good voice results. It has shown to be comparable to medialization thyroplasty in terms of vocal function improvement.
Various options available for injection laryngoplasty include autologous fat, Cymetra (LifeCell, Bridgewater, NY, USA), Radiesse (Merz Aesthetics, San Mateo, CA, USA), and other nonbiomaterials such as Gelfoam (Pharmacia and Upjohn, Pfizer, New York, NY, USA), silicone, and various gels.
Autologous fat has the advantage of being easily available, cheap, with no local or systemic inflammatory response. It has no risk of transmission of infection which is theoretically possible with Cymetra. Gelfoam, silicone, and other gels have shown to increase stiffness of the vocal fold leading to poor results.,
Other substances such as collagen and hyaluronic acid are known to have a short-term effect and as such cannot be used for long-term management of UVCP. Autologous fat typically lasts from one to several years and is considered to be a permanent solution. Since it is autologous and readily available, it can be injected generously. Substantial over injection is recommended owing to immediate variability of uptake of fat., Fat injections have shown not to interfere with the pliability of vocal folds.
In this study, we present a single institution study of patients of UVCP managed by autologous fat augmentation. We have studied the vocal outcomes using both qualitative and quantitative criteria. It is a comprehensive account of the use of autologous fat as a viable material for injection laryngoplasty with good phonatory outcomes.
| Materials and Methods|| |
This retrospective study was carried out at a tertiary care hospital in western India. Approval for the study was obtained from the ethical committee of the institution. Data from a period from July 2014 to July 2017 were collected from hospital records of patients who were diagnosed with UVCP of at least 6 months' duration and who underwent autologous fat injection medialization laryngoplasty. Patients were included in the study irrespective of gender, age, and etiology of palsy. Informed consent was taken from all participants in the study. Phonatory gap >3 mm was treated with open type 1 thyroplasty and was not included in the study. Patients who had a glottal level difference during video laryngoscopy were also treated using open techniques and excluded from this study. Sixty-seven patients were identified fulfilling all these criteria. All patients underwent preoperative voice evaluation using voice handicap index (VHI), grade, roughness, breathiness, asthenia, and strain (GRBAS) scale, and voice analysis software multidimensional voice program (MDVP) by KayPENTAX.
Patients were diagnosed with UVCP by video laryngostroboscopy. For autologous fat augmentation injection, a minimum duration of 6 months of palsy was the inclusion criteria. All procedures were done under general anesthesia. Fat was harvested from the lower abdomen – right paraumbilical region. We chose this site for abdominal fat harvesting as Indian women traditionally wear sarees and the cloth exposes the abdomen except the right paraumbilical region. Approximately 10cc of subcutaneous fat was harvested. It was broken down into uniform globules. Blood and fiber contents were separated. The needle used for injection is a traditional laryngeal injection needle of 23 gauge. Processed fat was passed once through the needle, and this was finally loaded into 1 ml syringe for injecting into vocal cord.
Transoral injection was performed at 1–2 sites. Apnea technique was used for ventilation. Apneic technique was preferred as the fat can sometimes be displaced or extruded when the endotracheal tube is withdrawn. The site for injection was chosen at the junction of a point just anterior to the vocal process of the arytenoid and laterally at the superior arcuate line. This site was chosen as it offers least need for a second injection. A second injection site carries the additional risk of extravasation of fat through the puncture site. The false cord was retracted by the needle, and 0.75–1.5 ml of fat was injected deep into the muscle tissue. Injection was continued till the cord achieved a convex shape. A 20%–30% overapproximation was confirmed by asking the anesthetist to make the plane of anesthesia light and allow the cords to approximate. All injections were done unilaterally in the affected cord.
Postoperative voice evaluation using VHI, GRBAS scale, and MDVP software was done at 6 weeks, and comparison was done using SPSS software (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). P < 0.05 was considered as statistically significant.
Subjective evaluation was done using GRBAS scale and VHI. GRBAS is a scale for perceptual analysis of voice where G (Grade) - voice quality, R (roughness) - abnormal fluctuations in fundamental frequency, B (breathiness) - air leakage, A (asthenicity) - impression of weakness, and S (strain) - impression of excessive force or tension. It is graded as 0 = normal, 1 = mild, 2 = moderate, and 3 = severe on the scale. A mean of 2 readings was considered to reduce subjective variations. Scoring was done independently and separately for each patient by 2 observers. Average value of their scores was taken for further evaluation.
VHI is a self-evaluation form developed by American Speech–Language–Hearing Association comprising 30 questions covering 3 domains: functional, physical, and emotional – to be filled by the patient. Each question has assigned a score of 0–4 (from least disability to most). In each domain, the maximum score is 40 points; <20 can be classified as mild disability, 21–30 as moderate, and more that 30 as severe. Adding the three scores together, the maximum possible is 120; the vocal disability can then be classified as mild (<30), moderate (31–60), severe (61–90), and very severe (91–120). VHI is shown in [Figure 1].
Objective acoustic analysis was performed using a voice analysis software MDVP by KayPENTAX. The software digitalizes the voice signal and then calculates the following acoustic parameters: fundamental frequency (F0), jitter or frequency variation (%), shimmer or amplitude variation (%), soft phonation index (SPI), and noise to harmonic ratio (NHR). The analysis was done while keeping a constant distance of 15 cm between the mic and the mouth of the patient. They were instructed to sustain the wave sound/ee/. A 3 s period of pronunciation of each vowel was used for acoustic analysis.
| Results|| |
Sixty-seven patients fulfilled the inclusion criteria and were part of the study. Seven patients however were lost to follow-up, and their data were found to be incomplete. Sixty patients who had a follow-up at 6 months were included in this study. Mean age of patients was 48 years (range 19–64 years). 38 were females and 22 were males. Left-sided palsy was found in 46 cases while 14 had right cord palsy. One patient had Ortner's Syndrome (compression of the recurrent laryngeal nerve due to enlarged atrium of the heart) and was operated for the same. The palsy resolved postsurgery, and he was not included in the study. The underlying cause for palsy was identified in 34 of the 60 cases. Seventeen patients developed palsy secondary to thyroid surgery, 5 patients had history of stroke and unilateral weakness while 4 patients had history of carotid body tumor excision surgery. Other causes included surgery of the esophagus, carcinoma of the breast surgery, parapharyngeal schwannoma excision, angioplasty, accidental strangulation, and road traffic accident.
A comparison of preoperative and 6-month postoperative voice analysis showed a significant improvement in VHI, all parameters of GRBAS scale, and improvement in Jitter, SPI, and NHR. There was no significant change in fundamental frequency and shimmer parameters.
The preop VHI ranged from 32 to 94 (mean 58), while the postoperative VHI ranged from 1 to 78 (mean 40). The mean difference was 18 and was statistically significant.
Perceptual Grade (G) of voice improved from a mean of 2.19 to a mean of 1.67. Similar improvement was noted in roughness (mean preoperative score 2 to mean postoperative score 1.51), breathiness (mean preoperative score 2.08 to mean postoperative score 1.43), asthenia (mean preoperative score 1.44 to mean postoperative score 0.89), and strain (mean preoperative score 2.2 to mean postoperative score 1) [Table 1].
The mean preoperative Jitter score of 5.80 improved to a mean postoperative score of 3.74. This was found to be statistically significant. Similar significant improvement was seen in SPI scores which improved from a preoperative mean of 19.23 to a postoperative mean of 13.78.
The improvement in NHR was also found to be significant with a decrease from a preoperative score of 0.32 to a postoperative score of 0.17.
Changes in fundamental frequency and shimmer parameters were not found to be significant. Fundamental frequency mean changed from 183 preoperatively to 182 postoperatively. Shimmer values changed from a mean preoperative value of 1.34–0.78 postoperative. The findings of MDVP analysis are summarized in [Table 2].
|Table 2: Comparison of mean pre- and post-operative multidimensional voice program scores|
Click here to view
| Discussion|| |
In the presence of a major glottic insufficiency due to cord immobility, speech therapy alone may fail to restore a normal voice. In fact, it may even facilitate compensatory phenomenon that can result in further worsening of voice. First described in 1919 by Bruennings using paraffin, vocal fold injection has become an accepted therapeutic methodology to medialize dysfunctional or damaged vocal folds.[10-12] In 1990, Mikaelian et al. used autologous fat for augmentation and praised the “soft bulkiness” it imparted to the treated fold as compared to the unnatural rigidity of injected Teflon.
Our study included 60 patients of UVCP having different etiologies. All of them presented with dysphonia. Eight patients had additional symptoms relating to aspiration. All patients underwent autologous fat augmentation under general anesthesia. The aspiration symptoms resolved postoperatively in all the patients. Four patients developed mild stridor in the immediate postoperative period which subsided after observation for a few hours. There were no cases that required surgical intervention for airway compromise after fat injection. This can be attributed to deliberate overcorrection on part of the surgeon along with some degree of local edema due to cord manipulation. Subjective and objective criteria were used to evaluate the vocal status of patients pre-operatively and 6-months post-operatively.
Our study shows a significant decrease in VHI score (mean score reduced by 18). Similar finding was obtained by Lodder and Dikkers. They also found a similar decrease in VHI using Radiesse. However, due to unavailability of Radiesse in India, and similar outcomes, we prefer autologous fat. Benninger et al. also found a reduction in VHI score by 23 points. However, both these studies did not compare the vocal parameters such as jitter, shimmer, NHR, and SPI.
GRBAS score showed an all-round improvement in all parameters. The improvement was statistically significant. The improvement was however more marked in B, A, and S criteria, i.e., there was a drastic improvement in breathiness, asthenicity, and strain while phonating. This can be attributed directly to better approximation of the vocal folds. A reduction in amount of air leak during normal phonation would contribute to lesser strain, decreased vocal fatigue and would also take away the breathiness in the voice. Stephenson et al. evaluated postoperative voice function in pediatric patients using GRBAS and found significant improvement following Radiesse injection. They also found improvement with fat augmentation, but it was not significant probably owing to the small sample size (n = 4).
We analyzed the voice of all patients using MDVP software and compared the change in Jitter, Shimmer, SPI, NHR, and fundamental frequency. Significant improvement was found in Jitter, SPI, and NHR. These can again be attributed to better approximation of the vocal folds postoperatively and also are a testament to the “soft bulkiness” of fat. Umeno et al. also studied these parameters and found significant improvement in all these parameters. They however did not evaluate the VHI and GRBAS scores. Khadivi et al. obtained a significant improvement in jitter and shimmer parameters. They did not evaluate any other parameter.
Our study is unique because it evaluates subjective perception of improvement of voice by both patients and laryngologists along with objective correlation using MDVP software. However, our study has a few drawbacks. A longer follow-up period would give a better idea as to the longevity of fat augmentation. Stroboscopy parameters were not evaluated in our study. Patient attrition can be attributed to the fact that patients travel long distances for treatment to our center.
| Conclusion|| |
Autologous fat augmentation is a simple, safe, and cost-effective method with excellent phonatory outcomes for the management of UVCP. Long-term follow-up studies evaluating both subjective and objective parameters would establish the place of fat augmentation as a permanent/semi-permanent measure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]