Every five years I make a list of the ten toughest problems in laryngology, said Jamie Koufman, MD, Director of the Voice Institute of New York. The number-one problem on the list from the beginning has been scarred vocal folds, and this hasn’t changed.
Dr. Koufman, who has practiced laryngology since 1981 and describes herself as an elder stateswoman in the field of laryngology, has observed that the unique anatomy of the vocal folds makes them difficult to repair once scarred. No treatment yet available will return the scarred vocal fold to normal, she commented, adding that it is one of those things that God makes right the first time, and we can’t make it exactly right again.
-Jamie Koufman, MD
Explaining this in anatomical terms, Chandra Ivey, MD, Associate Adjunct Surgeon in the Department of Otolaryngology-Head and Neck Surgery at the New York Eye and Ear Infirmary, said that once the fluid layer between the epithelium and vocal ligament has been damaged because of scarring, there is, as of yet, no good way to restore it. That layer, the superficial lamina propria, is needed to keep the vocal folds pliable and maintain good vocal fold vibration.
Although it is difficult, if not impossible, to return the vocal folds to a state of nature once scarred, finding a better way to help patients regain voice functioning disturbed by vocal fold scarring remains a top priority among laryngologists. This is particularly pressing given the frequency of this problem, which often occurs after radiation therapy, surgery, or even after heavy voice use (phonotrauma). Voice problems that develop include hoarseness, voice fatigue, and changes in pitch.
Treatments currently used, including steroids and vocal fold augmentation, are not that effective, and research continues to look at novel ways to treat this difficult problem.
One approach that has been used over the past years with little documented evidence of its safety or efficacy is the use of pulsed-dye laser. Preliminary data from the first study to look at this treatment, however, now provides the first evidence to date on a possible role for this treatment.
A Viable Treatment for Vocal Fold Scarring?
Presenting the data at the January meeting of the Triological Society, Peak Woo, MD, Professor of Otolaryngology at Mount Sinai School of Medicine in New York, reported on the preliminary results of the first 11 patients enrolled in the prospective study to look at the safety and efficacy of pulsed-dye laser treatment for vocal fold scarring (Mortensen MM, et al. Pulse dye laser in the treatment of vocal fold scar: a preliminary report.) Of the 11 patients, vocal fold scarring was due to phonosurgery in seven patients, radiation in two, and partial laryngectomy in two.
At six months, nine of the 11 patients had improved voice function after pulsed-dye laser, based on pre- and post-procedure measurements using the voice handicap index (VHI), laryngeal stroboscopy, acoustic analysis, and self-examination. In these nine patients, VHI improved from a mean of 51.09 to a mean of 41.63, the mean jitter improved from 2.147 to 1.514, and the mean shimmer from 3.59 to 3.11; the mean flow rate increased from 0.209 cc/sec to 0.236 cc/sec. No patients had worsening symptoms as shown on stroboscopy.
The results were good, said Dr. Woo. We didn’t hurt anybody and a significant number of people, although not totally normal, felt much better.
The study also included evaluation of the efficacy of pulsed-dye laser by three blinded observers who randomly looked at pre- and post-treatment vocal fold outcomes via stroboscopy. By a 29 to 4 margin, the post-treatment vocal folds were felt to vibrate better than the pretreatment vocal folds, said Dr. Woo.
Dr. Ivey, one of the investigators of the study, concurred. When the blinded reviewers looked at scarred vocal cords pre- and post-treatment, they reproducibly thought the post-treatment videos showed a more pliable epithelium with better voice.
The study is currently ongoing, and includes almost 30 patients. Although the preliminary data do suggest that the pulsed-dye laser is safe and has a possible role as an outpatient treatment for vocal cord scars, Dr. Woo emphasized that a number of questions remain-one of which is whether the treatment works in all scars. We don’t know how old these scars are, he said. Does it [pulsed dye laser] work with all scars, or is it better with new scars?
Another as-yet unanswered question is how much energy to use. According to Dr. Woo, the concept of using the pulsed-dye laser for vocal fold scars is the same as that for its use in dermatology to soften skin scars, and the energy they used in their study was based on what was previously published in the dermatologic literature. Just as in dermatology, the amount of energy to use is somewhat empirical, he said: That is the artistry of it.
If longer-term results continue to show voice improvements and no harmful effects, pulsed-dye laser treatment may offer an attractive option for both clinicians and patients as an outpatient procedure. In terms of technique, it is relatively easy for laryngologists. The technique used in the study, according to Dr. Ivey, was to deliver the pulsed-dye laser through a therapeutic flexible laryngoscope in a non-touch technique between 2 and 10 mm from the scarred vocal cord, often delivering 30 to 80 pulses with a power of 0.75 to 1.0 joule. Patients were given a topical anesthesia in the nose, posterior pharynx, and endolarynx. Patients underwent this office-based procedure monthly for three treatments.
For the patient, the procedure offers an office-based outpatient procedure that requires very little aftercare. The only recommendation by Dr. Woo is that patients rest their voices for three to four days following each treatment.
Further Evidence Needed
For Dr. Koufman, who, along with Dr. Woo, helped pioneer the use of the pulsed-dye laser to treat vocal fold scars, more data are needed to prove the applicability of the procedure beyond its current predominantly theoretical status.
Even with more data, however, she thinks that the procedure may only be useful for certain types of scarring. There will be no one-size-fits-all [treatment] even for vocal fold scarring, she said. There are too many variables. Sometimes you have soft tissue deficiency, so softening up won’t be enough. It makes a big difference if the scarring is one-sided or bilateral or if it is predominantly localized or involves the whole vocal fold. Postoperative scarring is also probably different than phonotrauma.
If the technique is used, Dr. Koufman thinks it most likely will be used for adynamic segments and for sulcus vocalis-a congenital or acquired condition in which there is a loss of the superficial lamina propria that runs along the edge of the vocal fold that makes contact during vocal fold vibration.
Whenever we have a new technology it looks great in the beginning, and then it finds its place in the surgical armamentarium with great specificity, she said.
For Dr. Woo, the response he is getting from his patients makes it worthwhile to pursue this treatment option. We’re pretty excited about this because we haven’t had anything to offer our patients before this, he said, adding that he has received many comments from his patients, many of whom have expressed quite dramatic and heartfelt responses to this treatment.
News & Notes
Sex, Drugs, and Cancer?
Some head and neck cancers have been linked to sexual activity and marijuana use, while others have been tied to tobacco and alcohol use, and poor oral hygiene, according to a study published in the March 11 online edition of the Journal of the National Cancer Institute.
Researchers from Johns Hopkins University, led by Maura L. Gillison, MD, PhD, conducted a hospital-based case-control study to compare the risk factor profiles for human papillomavirus (HPV)-16-positive and HPV-16-negative head and neck squamous cell carcinomas (HNSCCs). The study involved 240 individuals with HNSCC and 322 individuals without cancer, who were matched by age and sex to each HPV-16-positive and HPV-16-negative individual. All individuals were surveyed on risk behaviors via computer-assisted self-interview technology.
Researchers found that HPV-16 was detected in 92 of the individuals with HNSCC and that HPV-16-positive HNSCC was independently associated with several measures of sexual behavior and marijuana exposure. These associations increased in strength with having more oral sex partners, and with smoking more marijuana per month or having smoked marijuana for more years. However, HPV-16-positive HNSCC was not associated with cumulative measures of tobacco smoking, alcohol drinking, or poor oral hygiene.
Researchers also found that HPV-16-negative HNSCC was associated with measures of tobacco smoking, alcohol drinking, and poor oral hygiene, but not with sexual behaviors or marijuana use. These associations increased in strength with the number of cigarettes per day and having smoked for more years, heavier drinking, and having lost more teeth.
The authors conclude that because HPV-16-positive and HPV-16-negative HNSCCs have different risk factor profiles, they should be considered two different cancers.
©2008 The Triological Society