Bilateral vocal fold injection with autologous fat in patients with vocal fold atrophy with or without sulcus

European Archives of Oto-Rhino-Laryngology (2019) 276:2007–2013 https://doi.org/10.1007/s00405-019-05479-5 LARYNGOLOGY Bilateral vocal fold injection with autologous fat in patients with vocal fold atrophy with or without sulcus Emke M. J. M. van den Broek1,2 · Bas J. Heijnen1 · Martine Hendriksma1 · Vivienne A. H. van de Kamp‑Lam1 · Antonius P. M. Langeveld1 · Peter Paul G. van Benthem1 · Elisabeth V. Sjögren1 Received: 29 March 2019 / Accepted: 16 May 2019 / Published online: 27 May 2019 © The Author(s) 2019 Abstract Purpose To evaluate voice outcome after bilateral vocal fold injection with autologous fat in patients with non-paralytic glottic insufficiency due to vocal fold atrophy with or without sulcus. Methods This is a retrospective cohort study from September 2012 to December 2017 including 23 patients undergoing bilateral vocal fold injection with autologous fat (24 procedures) for vocal fold atrophy (15 procedures) or atrophy with sulcus (Ford type II or III) (9 procedures). Voice data were collected and analyzed for the preoperative and the 3- and 12-month postoperative time points according to a standardized protocol, including Voice Handicap Index (VHI)-30 and perceptive, acoustic and aerodynamic parameters. Failure rate was defined as non-relevant improvement (< 10 points) in VHI-30 at 12 months and number of revisions within 12 months. Results There was a clinically relevant (≥ 15 points) and statistically significant improvement in the VHI-30 (preoperative: 49.1 points; postoperative at 12 months: 29.7 points). Change in dynamic range was also statistically significant over time (p = 0.028). There were no differences in voice parameters between patients with atrophy only and atrophy with sulcus, although grade tended to be lower in patients with atrophy only over all time points. Conclusion This study shows that bilateral vocal fold injection with autologous fat is a beneficial treatment not only for patients with atrophy but also for patients with sulcus. A comparison of the results with those reported from other forms of sulcus surgery confirmed this finding. However, there is a need for further prospective studies comparing the short- and long-term effects of different techniques. Keywords Glottic insufficiency · Vocal fold atrophy · Sulcus · Autologous fat · Vocal fold injection Introduction Non-paralytic glottic insufficiency is a common cause of dysphonia. There are several underlying causes, including vocal fold atrophy. In our clinic, we routinely encounter three forms of vocal fold atrophy: vocal fold atrophy in presbyphonia, an adolescent form, and atrophy associated with congenital vocal fold scar in the form of sulcus [1]. If a sulcus is present it can be further classified as a physiologic * Emke M. J. M. van den Broek 1 Department of Otorhinolaryngology/Head and Neck Surgery, Leiden University Medical Centre, Albinusdreef 2, PO‑box 9600, 2300 RC Leiden, The Netherlands 2 Department of Otorhinolaryngology/Head and Neck Surgery, University Medical Centre, Utrecht, The Netherlands sulcus (Ford type I) or pathologic sulcus vocalis (Ford types II and III) with Ford types II and III corresponding to a sulcus vergeture and a sulcus vocalis in the classification by Bouchayer and Cornut [2, 3]. The main surgical treatment for atrophy without sulcus is vocal fold medialization, which can be achieved either by bilateral vocal fold injection (VFI) with a durable injectable such as autologous fat or calcium hydroxyapatite, or by bilateral medialization thyroplasty. For vocal fold atrophy with sulcus, several surgical techniques are used that are broadly divided into phonosurgical epithelium freeing techniques such as microflap formation, hydrodissection, angiolytic laser treatment and tissue engineering techniques on the one hand, and medialization techniques on the other. In their consensus report on vocal fold scar, the European Laryngological Society (ELS) considered medialization to be the least traumatizing procedure to the vocal fold and, 13 Vol.:(0123456789) 2008 therefore, suggested that it be used as the initial treatment for vocal fold scar, including sulcus [4]. However, it is also known that the results of medialization for vocal fold atrophy with scar, including sulcus, are less predictable than the results for glottic insufficiencies caused by atrophy alone, hypomobility, or paresis [5]. In this study, we evaluated the prospectively collected voice outcome data after bilateral VFI with autologous fat in patients with vocal fold atrophy with or without sulcus and compared our findings with those reported in the literature. Methods Patients This study was approved by the Leiden University Medical Centre Ethics Committee. All patients with non-paralytic glottic insufficiency who underwent bilateral VFI with autologous fat under general anesthesia (n = 32, procedures = 35) from September 2011 to December 2017 were retrospectively reviewed. Seven patients were excluded because of previous phonosurgery for sulcus (n = 1), paresis as another cause of glottic insufficiency (n = 2), or an underlying disease affecting the voice (n = 4) including Parkinson’s disease (n = 2), laryngeal dystonia (n = 1), and laryngeal papillomatosis (n = 1). Of the 25 remaining patients (28 procedures), 23 (24 procedures) had pre- and postoperative voice data with at least a complete Voice Handicap Index (VHI)-30 questionnaire and were included in the definitive analysis (Fig. 1). These patients had undergone bilateral VFI with autologous fat between September 2012 and December 2017. Fig. 1  Patient selection and inclusion and exclusion criteria 13 European Archives of Oto-Rhino-Laryngology (2019) 276:2007–2013 Voice data Voice outcome data were collected according to a standardized voice analysis protocol implemented preoperatively and at 3 and 12 months postoperatively. This protocol included patients’ self-assessments using the VHI-30, perceptual evaluation using the overall grade score of the GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale, aerodynamic evaluation with maximum phonation time (MPT) and dynamic range, and acoustic analyses including fundamental frequency (F0) and melodic range. The VHI-30 was the primary outcome parameter of the voice analysis protocol. It is a patient-based self-assessment tool consisting of 30 items, which are distributed over three domains: functional, physical, and emotional [6]. In the Dutch version of the VHI-30, a score of 15 points or more identifies patients with voice problems in daily life [7, 8]. Furthermore, a change in pre- and postoperative score of 10 points or more in the individual patient and 15 points or more for a group can be considered clinically relevant [8]. The voice was perceptually graded using the grade of the GRBAS scale ranging from zero to three [9]. Running speech samples in random order were graded by experienced listeners (two senior speech language therapists and (...truncated)