Voice Rest

Voice rest is commonly recommended after laryngeal surgery, but there is no clear consensus on the duration, type, or importance of voice rest in postoperative management of voice. The evidence that exists is limited to studies of adults, and a review of the literature revealed no studies of voice rest in children. Recommendations range from no rest at all to multiple weeks of total voice rest, with most otolaryngologists falling somewhere in the middle [1–3]. In a survey, 84/85 respondents recommended some form of voice rest following phonomicrosurgery with up to 14 days of complete voice rest or 35 days of relative voice rest, 7 days the most common recommendation for subepithelial lesions, and 1–4 days recommended for epithelial lesions [1]. Coombs et al. found that most otolaryngologists recommended 1–2 days of postoperative voice rest, but some recommended more than 7 days [3]. Behrman and Sulica found that 51.4% of otolaryngologists preferred complete voice rest, 62.3% preferred relative voice rest, and 15% preferred no voice rest at all [2]. Recommended durations of voice rest ranged from 0 to 14 days of complete voice rest, and 0–21 days of relative voice rest, with the most common duration being 7 days [2]. While otolaryngologists have clear preferences in their recommendations for voice rest, these are often based on experience or expert opinion, but not on the available research.

Much of the standard practice of voice rest is based on a study done in a canine model, in which the vocal fold mucosa was excised bilaterally, and voice rest was simulated by resection of the recurrent laryngeal nerve; based on this study, 2 weeks of voice rest was recommended [4]. A small number of studies have explicitly examined the effects of voice rest in patients after surgery. In a 2015 study, participants with 10 days of voice rest demonstrated longer maximum phonation times than those undergoing 5 days of voice rest, but there were no other significant findings [5]. Conversely, Kaneko et al. found that 3 days of voice rest followed by voice therapy showed better results than 7 days of voice rest in adults undergoing phonomicrosurgery for leukoplakia, carcinoma in situ, Reinke’s edema, polyp, or cyst. Specifically, patients demonstrated improved vibratory function as assessed by normalized mucosal wave amplitude (NWMA) on stroboscopy at 6 months postoperatively. Perceptual voice evaluation indicated more perceptually normal voice in the 3-day group than the 7-day group at 1 and 3 months, and acoustic findings and quality of life measures were better in the 3-day than the 7-day group at 1 month after surgery [6]. While optimal duration of voice rest cannot be determined based on these studies alone, it does suggest that earlier controlled phonation with voice therapy may be beneficial in functional outcomes.

The basic science literature on this can help guide clinicians in developing guidelines for voice rest and therapy but is likewise inconclusive on the role of both rest and vocalization on healing. Vocal fold healing and scar have been primarily examined in animal models [7–11]. For an excellent overview of wound healing for the clinician, see Thibeault and Gray or Branski et al. [12, 13] In brief, wound healing consists of three stages: inflammation (days 1–3), proliferation which is made up of angiogenesis and epithelization (days 3–30), and maturation (1 year or more). In the vocal folds, hemostasis is complete in 24 h, and the inflammation stage lasts for 4–7 days, and epithelization is complete in 7 days [12]. Research in pediatric wound healing indicates that it follows the same trajectory as healing in adults but at an accelerated rate; in children, fibroblasts are present in greater numbers, collagen and elastin are produced more rapidly, and granulation tissue forms more quickly [14]. The human infant and pediatric vocal fold differs from the adult in terms of layer structure and distribution of collagen and hyaluronic acid [15, 16]. The infant lamina propria consists of a monolayer, and the layer structure differentiation is not complete until adolescence [16, 17]. Because of these differences, we cannot make assumptions that healing and scar in pediatric vocal folds will be identical to adults.

Vocal fold lamina propria is a form of connective tissue, although unique in composition and features. As such, some parallels can be drawn with orthopedic rehabilitation. The role of rest versus controlled mobilization has been discussed at length in the orthopedic literature, and current research indicates that long-term immobilization has a deleterious effect on healing, including atrophy and alterations in the makeup of connective tissue, while controlled mobilization of the injured area has positive impact on functional outcomes [18–22]. It is not clear if this can be generalized to the vocal folds, as there are differences in the nature of the tissues and the type, frequency, and duration of mobilization required.

The effects of rest and mobilization on tissue healing have not been studied in human vocal folds, but research has been done using animal models and bioreactors. With artificially induced phonation in a rabbit model, Rousseau et al. found increases in gene expression of metallopeptidase (MMP)-1, an enzyme that breaks down collagens I and II, no changes in expression of MMP-9, and no changes in interleukin-1β (involved in inflammation), suggesting that vocal fold vibration may impact gene expression involved in healing.

Using a bioreactor to control mechanical stress on vocal fold fibroblasts, Titze et al. found that genes associated with the extracellular matrix expressed more with mechanical stress than with rest [23]. Kutty and Webb found that vocal fold fibroblasts exposed to vibration showed increased expression of hyaluronic acid synthase 2, fibromodulin, and decorin compared to fibroblasts that were kept still, while collagen and elastin were not significantly affected by vibration, indicating that mobilization plays a role in gene expression and likely influences tissue healing [24].

Adherence to voice rest is difficult in adults and is assumed to be especially difficult in children. Rousseau et al. found that overall compliance with voice rest was 34.5%, although it was higher after surgery than for other reasons [25]. Compliance with voice rest in children has not been studied but, given developmental considerations, is not likely to be better than in adults. As such, during preoperative counseling we discuss strategies for communication when not speaking, which may include use of paper and pen, low-tech strategies such as a picture board with commonly used phrases and requested items, or more high-tech options including text-to-speech apps for phone or tablet for children who can write. The use of a simple text-to-speech app has been shown to result in higher self-reported communicative effectiveness in adults on voice rest after surgery [25]. Activities that are enjoyable but do not require talking can be brainstormed, and parents and children can discuss special privileges they might get during their recovery, such as a special coloring book or the chance to watch a preferred show or movie.

Voice Therapy

Voice therapy is generally accepted by clinicians as helpful in the postoperative period, although again there is little agreement on when to begin, how much to do, and what type of therapy is most helpful. Koufman and Blalock found that in adults, preoperative voice therapy was associated with reduced postoperative dysphonia [26]. There is no evidence that clearly indicates one approach to therapy as favorable to another. In clinical practice, the decision on what to do in therapy often depends greatly on the age of the child, the type of laryngeal lesion, and the type of surgery. In the case of benign lesions, children will generally have had a course of behavioral voice therapy prior to considering surgical excision. Ideally, the child will have multiple sessions of therapy prior to surgery, to reduce maladaptive compensatory behaviors associated with the vocal pathology, achieve optimal voicing, and train vocal exercises. One session of therapy prior to surgery should focus on discussion of voice rest recommendations, strategies for adherence to voice rest, and training of postoperative voice therapy exercises and target voice. Kaneko et al. used tube phonation (a form of semi-occluded vocal tract exercise) for 6 weeks postoperatively. Resonant voice exercises were used by Verdolini Abbott and colleagues in studying the effect of voice therapy vs voice rest on phonotrauma [27]. They studied participants after an intense vocal loading task assumed to cause phonotrauma and found that certain markers of inflammation in the vocal fold secretions were reduced after resonant voice exercises compared with both spontaneous speech and voice rest [27]. While this cannot be clearly generalized to recovery after surgery, it is encouraging in the role of large-amplitude, low-impact vibrations (as present in resonant voice therapy and semi-occluded vocal tract exercises) in the role of healing. Voice exercises such as cup bubbles, straw phonation, lip trills, resonant humming, and gentle pitch glides are frequently employed, as they are instrumental in coordinating subsystems of voice and facilitating optimal glottal configuration and vibration during voicing. Clinicians may work on resonant voice-based therapy (e.g., Lessac-Madsen resonant voice therapy) or flow phonation to bring the efficiency and coordination into connected speech. As with all voice therapy, clinicians should tailor their approach to both their knowledge of the anatomy and physiology postoperatively and the individual learning style and needs of the patient.

In summary, the available evidence indicates that some degree of voice rest followed by controlled voicing and voice therapy is optimal for functional recovery after surgery. Based on the wound healing literature, our clinical practice is typically to recommend 3 days of complete voice rest, with some voice conservation for 2 weeks, and early implementation of semi-occluded vocal tract exercises and resonant voice beginning 3 days after surgery. We recommend voice therapy continuing for 2–3 months after surgery as there are likely changes continuing to occur in the vocal fold tissue, and patients may need assistance in adapting to these changes and maximizing their vocal gains.

Reflux Treatment

Empiric treatment to prevent laryngopharyngeal reflux during the perioperative period is controversial. It would seem obvious that acid reflux would be detrimental to wound healing as it has been implicated in laryngotracheal injury [28–30]. That said, however, empiric treatment may not come without risk. Neutralization of the stomach may allow for pathogenic bacterial overgrowth which may be detrimental to a positive outcome. Personal experience can testify to gastric pseudomonal overgrowth and subsequent cartilage graft loss after laryngotracheal reconstruction and perioperative empiric proton pump therapy. Prudent use of proton pump inhibitors and prophylactic antibiotics are commonly employed and likely promote healing and graft survival although distinct scientific study is lacking. The exact timing of acid suppression and antibiotic therapy is not known. Time for wound healing and reepithelialization would seem to be the key for treatment length. Four to 12 weeks of acid suppression is typical after airway reconstruction or microlaryngeal surgery.

The implications of the change in the microbiome secondary to acid suppression and antibiotics treatment is beginning to pique interest in clinicians [31–33]. Empiric acid suppression and antibiotic usage may have unintended and seemingly counterintuitive outcomes. If laryngopharyngeal reflux is known or significantly suspected, however, treatment is important. A proton pump inhibitor is indicated when a diagnosis of laryngopharyngeal reflux is supported. Other treatments such as H2 blockers may be used when the suspicion is lower. As the literature is lacking, personal preference often plays a role in the treatment of patients postoperatively after laryngeal surgery or airway reconstruction. The prevention of caustic exposure from acidic gastric contents must be balanced with the potential disruption and change to the microbiome of the patient and its potential long-term effects.

Perioperative Steroids

Perioperative steroids are often used after airway reconstruction or phonomicrosurgery for the prevention of scar formation and to decrease swelling, assisting in airway management. Oral, intralesional and other parenteral administration of steroids have been utilized for this purpose [34–36]. Intralesional dexamethasone has been used to hydrodissect the epithelium away from the laryngeal lesion with the added benefit of decreasing the risk of scar formation. Care must be taken as there is a risk of causing temporary atrophy of the vocal fold with intralesional injection [37]. Intraoperative intralesional injections with dexamethasone are used during laryngeal phonosurgery. Intravenous dexamethasone is used during the 24–48 h prior to extubation after airway reconstruction. It would be rare to use prolonged oral steroids in the perioperative period.

Voice Rest

As outlined above, there is a sweet spot for voice rest after phonomicrosurgery. The precise length of voice rest and the timing of reinstituting graded phonation for optimal outcome have not been well studied. As stated above, we prescribe 3 days of absolute voice rest followed by 2 weeks of conservative voice use, progressing back to full voicing after this time. We would typically wait until we feel confident that the child can complete this course of voice rest prior to performing phonomicrosurgery. There are no hard rules for when a child will be able to follow the voice rest protocol and must be assessed individually. Typically, children will be older than 4 or 5 years of age, although depending on the urgency of surgery and the temperament of the child, this may be older or younger.