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Autologous transplantation of fascia into the vocal fold: A new phonosurgical technique for glottal incompetence

1999; Wiley; Volume: 109; Issue: 3 Linguagem: Inglês

10.1097/00005537-199903000-00030

1531-4995

Koichi Tsunoda, Minako Takanosawa, Seiji Niimi,

Tracheal and airway disorders

Glottal incompetence is one of the causative condition of hoarseness. There have been various methods to improve the glottal conditions. However, each method has advantages and disadvantages as well. Sulcus vocalis is one of the most difficult problems facing the laryngeal surgeon. Clinically, most authors have reported that laryngoscopy in cases of sulcus vocalis reveals bowed vocal folds,1, 2 resulting in a spindle-shaped chink with glottal incompetence. The anatomic and functional problems and the resulting incomplete glottal closure during phonation lead to presenting symptoms of breathy hoarseness, decreases in maximum phonation time (MPT), and vocal fatigue.1 The ventricular folds are frequently overadducted during phonation in an attempt to compensate for the glottic incompetence.1 Many therapeutic methods have been reported for sulcus vocalis and glottal incompetence. The aim of surgical treatments reported by most authors has been to produce sufficient glottal closure in phonation. Techniques that have been used toward this end include injection of Teflon,3 collagen,4-8 or autologous fascia9 into the vocal folds. To achieve satisfactory glottal closure to prevent breathy phonation in cases of sulcus vocalis, we have been trying a new surgical technique for this severe glottal incompetence, called "vocal fold autologous transplantation." Our case was a 57-year-old Japanese man admitted to the otolaryngology and phonosurgery clinic in Tamagawa General Hospital, Tokyo, Japan, with gradual progressive hoarseness over more than 5 years. We recognized breathy hoarseness; MPT was only 5 seconds. Laryngoscopy showed bilateral sulcus vocalis with bowed vocal folds during inhalation and with insufficient glottic closure and a constriction of supralaryngeal structures (particularly at the ventricular folds) during phonation. The patient strongly wished to improve his voice, so we injected a bovine collagen (3% atelocollagen, Koken, Japan) in both vocal folds (right side, 0.8 cc; left side, 0.8 cc), with the patient under general anesthesia. The injection technique was the same as the method proposed by Ford.7 The collagen injection into both vocal folds was performed in September 1995. After the surgery, the glottal chink disappeared and MPT elongated to 10 seconds (a gain of 5 s). However, this improvement lasted only about 1 month. In attempting to resolve this patient's voice problem, we performed collagen injection four times. Each time, the breathy voice improved and MPT increased after surgery, but these effects continued only 1 to 2 months. As voice quality then deteriorated and MPT decreased, the adduction of the ventricular folds also returned. In response to these problems in achieving a lasting improvement, we planned a completely different approach for this patient's voice problems. Our phonomicrosurgical technique for autologous transplantation of fascia into the vocal fold comprised the following steps: 1. undermining under the vocal fold mucosa to make a pocket, 2. preparation of fascia temporalis, and 3. autologous transplantation into the vocal fold. Since this was the first operation with this technique, we tried the surgery on only one vocal fold (the left). Surgery was performed in April 1997. Details of the technique are as follows. Autoplastic transplantation of fascia into left side of vocal fold. A. Lateral incision in the top of the left vocal fold epithelium. B. Cut sharply to separate the sulcus from the vocal fold ligament. C. Dissect the cover from the body to a depth of 3 mm below the sulcus. D. Fascia temporalis on the left vocal fold. E. Insert fascia temporalis into the pockets. F. Adjust the shape of the vocal fold. Place an anterior-to-posterior directed incision laterally on the superior surface of vocal fold to just above the vocal ligament. The incision should only penetrate the epithelium and superficial lamina propria (Fig. 1A). Dissect gently to separate the sulcus from the vocal fold ligament, from lateral to median. (During this manipulation the adhesion between the epithelium of the sulcus and corresponding ligament is found.) Cut sharply to separate the sulcus from the vocal fold ligament (Fig. 1B). Continue to dissect the cover (including the sulcus) from the body to a depth of 3 mm below (subglottal to) the sulcus (Fig. 1C). This step creates a pocket between the cover and body of the vocal fold. Excise a piece of fascia temporalis for autotransplantation. Insert a piece of sterilized paper into the pocket, and trim the paper to a suitable size. The size we designed was only slightly smaller than the size of the pocket. Cut the fascia temporalis to the same size as the trimmed, sterilized paper. Insert the fascia temporalis (Fig. 1D) into the pocket between the body and cover of the vocal fold (Fig. 1E). Adjust the shape of the vocal fold and fill any dead space completely (Fig. 1F). Cover the incision of Step 1 completely with surrounding epithelium. Compared with the bilateral collagen injections, unilateral application of the new technique produces a greater improvement in MPT. MPT increased by 10 seconds (from 5 to 15 s). Voice quality also improved. Stroboscopy showed better glottal closure and improved vocal fold vibrations during phonation. Hyperadduction of the ventricular folds and constriction of the supralaryngeal structures disappeared completely (Fig. 2). Furthermore, 4 weeks after the surgery, stroboscopic observation revealed a mucosal wave on the operated vocal fold. Six months after the surgery the improved voice remained and the MPT remained at its higher level (Fig. 3). Therefore we operated with this technique on the right-side vocal fold in October 1997. Seven months after second surgery (i.e., after bilateral surgery: left, 13 mo; right, 7 mo), MPT increased by 17 seconds (from 5 to 22 s). Voice quality also improved dramatically and remained in its improved state (Fig. 3). The patient's voice was analyzed by using the computer program "Song."10 The results are shown in Figure 3A–C. Sulcus vocalis may affect only the superficial layer of the lamina propria, but there is often direct attachment of the epithelium to the ligament.1 Sato and Hirano11 demonstrated the increased thickness of the basement membrane and also a lack of suitable elastic and collagen fibers in the lamina propria. In our case, the epithelium was attached directly to the ligament. Any infiltration or scar tissue in this area interferes with vocal fold vibrations and causes pathological voice. In our present case, the patient's chief complaint was his severely breathy voice, like a stage whisper. Surgical injection of collagen on four occasions was not satisfactory in correcting this symptom, and the collagen disappeared in a short period (2 to 8 w) each time. This lack of permanence is related to the injection of collagen being a kind of heterologous transplantation and collagen being absorbable. To conquer these shortcomings, we inserted a piece of fascia under the mucosal epithelium to increase the vocal fold volume. Since our technique does not utilize any synthetics or foreign tissues, we assume it to be at low risk for infection and also immunologically safe. It will, of course, be necessary to evaluate a long-term course of the autofascia implant. Six months after the unilateral (left side) surgery. A. On inhalation, sulcus had disappeared on the left vocal fold. B. Better glottal closure during phonation is evident. Hyperadduction of the ventricular folds disappeared on the left side. Compared with our previous bovine collagen injections, autologous transplantation of fascia, was effective from the anatomical, physiological and phoniatric points of view. The acoustical profiles of the patient's voice analysis (described by Imaizumi.10). A. Before the transplantation. B. Six months after the unilateral (left side) transplantation. C. Seven months after second transplantation (i.e., after bilateral surgery: left side, 13 mo; right side, 7 mo). We thank Dr. Thomas Baer for helpful and kindly physiological comments, Dr. Tomoko Konishi for voice analysis, Dr. Shigeru Kano, Dr. Niro Tayama and Dr. Akira Nakajima for surgical advice.