Abstract
Purpose
Removal of benign vocal fold lesions results in small to moderate-sized mucosal defect on vocal fold, which heals by secondary intention. Microsuturing this defect leads to primary wound healing with fastened recovery and less scar. However, its value has not been determined.
Materials and methods
This is prospective, randomized, and controlled study performed in university hospital. Forty adults with vocal polyp, cyst, and Reinke’s edema were included. Preoperatively, all patients completed VHI (Voice Handicap Index)–30, had acoustic analysis with continuous /a/ and videolaryngostroboscopy (VLS). The patients were randomly assigned to study group (with 1 or 2 6/0 vicryl suture) (n = 20) or control group (n = 20). Postoperative follow-up was done at the first, second, and fourth weeks. During follow-up examinations, VLS was repeated; the patients completed VHI-30 and had an acoustic analysis again.
Results
All patients recovered with normal VLS and without complications; all were satisfied with the treatment result. The VHI results and acoustic analysis parameters of the study group were statistically significantly better than those of the control group at the first postoperative week ( P < .05) but not at the second and fourth weeks ( P > .05). Normal VLS was obtained significantly more early in the study group compared with the control group ( P < .05).
Conclusions
Microlaryngoscopic removal of benign vocal fold lesions is a safe, satisfying procedure with excellent to good results if done according to its principles. Microsuturing of the mucosal defect helps to speed up recovery, although final result remains to be clinically unchanged. It may be beneficial for professional voice users by making early return of vocal fold function possible.
1
Introduction
Many of the benign vocal fold lesions are removed surgically under microlaryngoscopy. This removal results in small to moderate-sized mucosal defect on the vocal fold, if flap technique is not used. This defect heals by secondary intention, usually leaving no voice complaints. This defect may be sutured during the same operation setting, thus leading to primary wound healing. Primary wound healing leads to fastened recovery of the surgical area and less scar formation. If flap technique is used and it is let to adhere by clot formation, this flap may open up easily by cough or unintended phonation, leaving the wound to secondary intention again. Microsuturing of the flap may prevent such unwanted consequences.
Even very little scar formation on the vocal fold may have serious detrimental effects on voice, especially of the professional voice user. Microsuturing costs extra time and effort; however, its value has not been determined in the medical literature, yet.
2
Methods
Forty adult patients with a diagnosis of vocal fold polyp, cyst, and Reinke’s edema were included in the study. Patients with a diagnosis of glottic web and sulcus vocalis were excluded.
Hacettepe University Faculty of Medicine Ethics Committee approved the study (07/41-20). The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. Informed consent was obtained from all patients. Primary outcome measures were stroboscopy, acoustic analysis, and Voice Handicap Index (VHI).
All diagnoses were made with videolaryngostroboscopy (VLS) (Kay Pentax Digital Strobe, Model 9200C; Kay Pentax, NJ). During VLS, glottal closure, mucosal wave amplitude, symmetry, and periodicity were evaluated on a scale of 0 to 3, 0 being normal; 1, mild; 2, moderate; and 3, severe abnormality. Preoperatively, all patients completed VHI form with 30 items and had an acoustic analysis with continuous /a/. All acoustic parameters were measured, but only fundamental frequency (Fo), jitter percentage, shimmer in decibels, and noise-to-harmonics ratio (NHR) were evaluated. Primary end point was normal VHI-30; secondary end points were normal acoustic parameters and normal VLS.
Acoustic analysis was done using the MDVP program of CSL Model 4300B (Kay Elemetrics, NJ) with a microphone SHURE SM 48 (Shure Inc., Mexico) in a soundproof room. The microphone was kept 15 cm away and off the axis from the mouth. The procedure was instructed and demonstrated twice to each patient, and the patient performed the procedure twice off the record. Three recordings with continuous /a/ with comfortable pitch and loudness were done, each 4 seconds long. The mean of the 3 values was calculated and taken for the study.
The patients were assigned to the study group (with suture) (n = 20) or the control group (without suture) (n = 20) according to their number to enter the operation. Odd numbered patient’s mucosal defect was closed with 1 or 2 6/0 vicryl sutures on 1 vocal fold, whereas even numbered ones were left unsutured.
Two nonlocking microlaryngeal straight forceps and a knot pusher are used during suturing. 6/0 vicryl suture with 8-mm long, reverse cutting, curved needle with at least 45-cm thread length is necessary. After the needle is passed through both mucosal edges, the needle is pulled out of the laryngoscope while the other end of the thread is held by the assistant. The surgical knot is tied outside the laryngoscope, and the knot is pushed inside the laryngoscope while the surgeon is holding one end of the suture and the assistant is holding the other end. As the knot is tightened, the assistant applies counterforce only; the surgeon applies force to the other end of the suture, and the knot pusher as required. A simple knot is tied outside the laryngoscope again, and aforementioned steps are repeated. As many simple knots as necessary may be used. At the end of the suturing, the thread is cut with microscissors close to the knot ( Fig. 1 A–C , Fig. 2 A–C , Fig. 3 A–C , Fig. 4 A–C , Fig. 5 A and B ).
All patients were operated with microlaryngoscopy under general anesthesia with orotracheal intubation. All operations were performed by the first author, and VHI, acoustic analysis, and VLS were done by the second author, who was not informed about the condition of the patient. Total blinding was impossible because the second author would see the sutures during follow-up examinations. All patients had a complete voice rest for 7 days postoperatively. Postoperative follow-up was done at the end of the first, second, and fourth weeks. During follow-up examinations, VLS was repeated; the patients completed VHI-30 form and had an acoustic analysis with continuous /a/ again. During VLS, the disappearance from view of the suture was marked. The period for the VLS to become totally normal was recorded.
SPSS for Windows 10.0 (SPSS, Inc, Chicago, IL) was used for statistical analysis. χ 2 Test, Student t test for independent samples, and Student t test for paired samples were used for statistical comparison of both groups. The significance was taken as P < .05.
2
Methods
Forty adult patients with a diagnosis of vocal fold polyp, cyst, and Reinke’s edema were included in the study. Patients with a diagnosis of glottic web and sulcus vocalis were excluded.
Hacettepe University Faculty of Medicine Ethics Committee approved the study (07/41-20). The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. Informed consent was obtained from all patients. Primary outcome measures were stroboscopy, acoustic analysis, and Voice Handicap Index (VHI).
All diagnoses were made with videolaryngostroboscopy (VLS) (Kay Pentax Digital Strobe, Model 9200C; Kay Pentax, NJ). During VLS, glottal closure, mucosal wave amplitude, symmetry, and periodicity were evaluated on a scale of 0 to 3, 0 being normal; 1, mild; 2, moderate; and 3, severe abnormality. Preoperatively, all patients completed VHI form with 30 items and had an acoustic analysis with continuous /a/. All acoustic parameters were measured, but only fundamental frequency (Fo), jitter percentage, shimmer in decibels, and noise-to-harmonics ratio (NHR) were evaluated. Primary end point was normal VHI-30; secondary end points were normal acoustic parameters and normal VLS.
Acoustic analysis was done using the MDVP program of CSL Model 4300B (Kay Elemetrics, NJ) with a microphone SHURE SM 48 (Shure Inc., Mexico) in a soundproof room. The microphone was kept 15 cm away and off the axis from the mouth. The procedure was instructed and demonstrated twice to each patient, and the patient performed the procedure twice off the record. Three recordings with continuous /a/ with comfortable pitch and loudness were done, each 4 seconds long. The mean of the 3 values was calculated and taken for the study.
The patients were assigned to the study group (with suture) (n = 20) or the control group (without suture) (n = 20) according to their number to enter the operation. Odd numbered patient’s mucosal defect was closed with 1 or 2 6/0 vicryl sutures on 1 vocal fold, whereas even numbered ones were left unsutured.
Two nonlocking microlaryngeal straight forceps and a knot pusher are used during suturing. 6/0 vicryl suture with 8-mm long, reverse cutting, curved needle with at least 45-cm thread length is necessary. After the needle is passed through both mucosal edges, the needle is pulled out of the laryngoscope while the other end of the thread is held by the assistant. The surgical knot is tied outside the laryngoscope, and the knot is pushed inside the laryngoscope while the surgeon is holding one end of the suture and the assistant is holding the other end. As the knot is tightened, the assistant applies counterforce only; the surgeon applies force to the other end of the suture, and the knot pusher as required. A simple knot is tied outside the laryngoscope again, and aforementioned steps are repeated. As many simple knots as necessary may be used. At the end of the suturing, the thread is cut with microscissors close to the knot ( Fig. 1 A–C , Fig. 2 A–C , Fig. 3 A–C , Fig. 4 A–C , Fig. 5 A and B ).
