Implantation of Esterified Hyaluronic Acid in Microdissected Reinke's Space After Vocal Fold Microsurgery: Short- and Long-Term Results

Published:October 23, 2009DOI:https://doi.org/10.1016/j.jvoice.2008.12.015

      Summary

      In this study are reported the laryngeal and vocal results obtained after a microflap excision of benign vocal fold (VF) lesions and immediate implantation of esterified hyaluronic acid (EHA) in the surgical wound. In a previous pilot study on 11 cases, we have shown an excellent tolerance of this bioimplant. The objectives are to confirm the innocuity of the technique, to demonstrate the laryngeal and vocal evolution at short and long term, and to evaluate the eventual positive impact of EHA implantation on the pliability of the superficial layer of the lamina propria (SLLP) and on voice. This is a prospective and comparative study on 83 patients suffering from various benign VF lesions. Thirty-three patients were implanted with EHA, whereas 50 patients did not undergo implantation at the end of the microsurgical procedure. All patients undergo rigid laryngoscopy and microflap excision procedure under general anesthesia. After freeing up of the Reinke's space and creation of a mucosal microflap, a few fibers of EHA are inserted in the surgical wound, before closure of the incision with fibrin glue. Serial laryngeal and vocal assessments are performed in all patients using videostroboscopy (Wolff and Xion), perceptual and objective voice evaluation (MDVP software, Kay Elemetrics), and phonatory function measurements (Aerophone II). Pre- and early postoperative means are compared by analysis of variance. Delayed and long-term evolution of laryngeal and vocal data are compared by means of nonparametric statistical methods. The longest follow-up in the implanted group is 4 years. Early postoperative results are similar in both groups: a significant improvement of a majority of laryngeal and vocal data is observed after microsurgery. In the long term, the two groups exhibit a different behavior: further improvement of voice, as an ongoing process, is only observed in the EHA implanted group, together with improvement of some videostroboscopic characteristics. The nonimplanted group remains stable, with no further improvement of the voice quality obtained after microsurgery. Excellent short- and long-term tolerance of EHA implantation is confirmed by this larger series. The use of EHA implant in microdissected SLLP is safe and leads to good laryngeal and vocal outcomes in the treated patients. More interestingly, treated cases exhibit a continuous improvement over a long period of time.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Voice
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ward P.D.
        • Thibeault S.L.
        • Gray S.D.
        Hyaluronic acid: its role in voice.
        J Voice. 2002; 16: 303-309
        • Butler J.E.
        • Hammond T.H.
        • Gray S.D.
        Gender-related differences of hyaluronic acid distribution in the human vocal fold.
        Laryngoscope. 2001; 111: 907-911
        • Gray S.D.
        • Titze I.R.
        • Chan R.
        • Hammond T.H.
        Vocal fold proteoglycans and their influence on biomechanics.
        Laryngoscope. 1999; 109: 845-854
        • Chan R.W.
        • Gray S.D.
        • Titze I.R.
        The importance of hyaluronic acid in vocal fold biomechanics.
        Otolaryngol Head Neck Surg. 2001; 124: 607-614
        • Balazs E.A.
        • Larsen N.E.
        Hyaluronan: aiming for perfect skin regeneration.
        in: Garg H.G. Scarless Wound Healing. Marcel Dekker, New York2000: 143-160
        • Thibeault S.L.
        • Rousseau B.
        • Welham N.V.
        • Hirano S.
        • Bless D.M.
        Hyaluronan levels in acute vocal fold scar.
        Laryngoscope. 2004; 114: 760-764
        • Finck C.
        • Lefebvre P.
        Implantation of esterified hyaluronic acid in microdissected Reinke's space after vocal fold microsurgery: first clinical experiences.
        Laryngoscope. 2005; 115: 1841-1847
        • Uloza V.
        Effects on voice by endolaryngeal microsurgery.
        Eur Arch Otorhinolaryngol. 1999; 256: 312-315
        • Woo P.
        • Casper J.
        • Colton R.
        • Brewer D.
        Aerodynamic and stroboscopic findings before and after microlaryngeal phonosurgery.
        J Voice. 1994; 8: 186-194
        • Zeitels S.M.
        • Hillman R.E.
        • Bunting G.W.
        • Vaughn T.
        Reinke's edema: phonatory mechanisms and management strategies.
        Ann Otol Rhinol Laryngol. 1997; 106: 533-543
        • Chan R.W.
        • Titze I.R.
        Viscosities of implantable biomaterials in vocal fold augmentation surgery.
        Laryngoscope. 1998; 108: 725-731
        • Hertegård S.
        • Hallén L.
        • Laurent C.
        • Lindström E.
        • Olofsson K.
        • Testad P.
        • Dahlqvist A.
        Cross-linked hyaluronan versus collagen for injection treatment of glottal insufficiency: 2-year follow-up.
        Acta Otolaryngol. 2004; 124: 1208-1214
        • Caton T.
        • Thibeault S.L.
        • Klemuk S.
        • Smith M.E.
        Viscoelasticity of hyaluronan and nonhyaluronan based vocal fold injectables: implications for mucosal versus muscle use.
        Laryngoscope. 2007; 117: 516-521
        • Chan R.W.
        • Titze I.R.
        Hyaluronic acid (with fibronectin) as a bioimplant for the vocal fold mucosa.
        Laryngoscope. 1999; 109: 1142-1149
        • Chan R.W.
        • Titze I.R.
        Viscoelastic shear properties of human vocal fold mucosa: measurement methodology and empirical results.
        J Acoust Soc Am. 1999; 106: 2008-2021
        • Klemuk S.A.
        • Titze I.R.
        Viscoelastic properties of three vocal-fold injectable biomaterials at low audio frequencies.
        Laryngoscope. 2004; 114: 1597-1603
        • Hallen L.
        • Dahlqvist A.
        • Laurent C.
        Dextranomeres in hyaluronan (DiHA): a promising substance in treating vocal cord insufficiency.
        Laryngoscope. 1998; 108: 393-397
        • Hallen L.
        • Testad P.
        • Sederholm E.
        • Dahlqvist A.
        • Laurent C.
        DiHA (dextranomers in hyaluronan) injections for treatment of insufficient closure of the vocal folds: early clinical experiences.
        Laryngoscope. 2001; 111: 1063-1067
        • Hertegård S.
        • Hallén L.
        • Laurent C.
        • Lindström E.
        • Olofsson K.
        • Testad P.
        • Dahlqvist A.
        Cross-linked hyaluronan used as augmentation substance for treatment of glottal insufficiency: safety aspects and vocal fold function.
        Laryngoscope. 2002; 112: 2211-2219
        • Hsiung M.W.
        • Lin Y.S.
        • Su W.F.
        • Lee J.C.
        • Wang H.W.
        Fat augmentation following microsurgical removal of the vocal nodules: long-term results.
        ORL J Otorhinolaryngol Relat Spec. 2003; 65: 169-175
        • Longaker M.T.
        • Chiu E.S.
        • Adzick N.S.
        • Stern M.
        • Harrison M.R.
        • Stern R.
        Studies in fetal wound healing. V. A prolonged presence of hyaluronic acid characterizes fetal wound fluid.
        Ann Surg. 1991; 213: 292-296
        • Huang-Lee L.L.
        • Wu J.H.
        • Nimni M.E.
        Effects of hyaluronan on collagen fibrillar matrix contraction by fibroblasts.
        J Biomed Mater Res. 1994; 28: 123-132
        • Rydell N.
        Decreased granulation tissue reaction after installment of hyaluronic acid.
        Acta Orthop Scand. 1970; 41: 307-311
        • King S.R.
        • Hickerson W.L.
        • Proctor K.G.
        Beneficial actions of exogenous hyaluronic acid on wound healing.
        Surgery. 1991; 109: 76-84
        • Day A.J.
        • Prestwich G.D.
        Hyaluronan-binding proteins: tying up the giant.
        J Biol Chem. 2002; 277: 4585-4588
        • Savani R.
        • Bagli D.J.
        • Harrisson R.E.
        • Turley E.A.
        The role of hyaluronan receptor interactions in wound repair.
        in: Scarless Wound Healing. Marcel Dekker, New York2000: 115-137
        • Wang F.
        • Garza L.A.
        • Kang S.
        • Varari J.
        • Orringer J.S.
        • Fisher G.J.
        • Voorhees J.J.
        In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photo-damaged human skin.
        Arch Dermatol. 2007; 143: 155-163
        • Breuing K.
        • Eriksson E.
        • Liu P.
        • Miller D.
        Healing of partial thickness porcine wounds in a liquid environment.
        J Surg Res. 1991; 52: 50-58
        • Arnold F.
        • Jia C.
        • Cherry G.W.
        • Carbow B.
        • Meyer-Ingold W.
        • Bader B.
        • Wes D.C.
        Hyaluronan, heterogenity and healing: the effects of ultrapure hyaluronan of defined molecular size on the repair of full-thickness pig skin wounds.
        Wound Repair Regen. 1995; 3: 299-310
        • Andre P.
        Evaluation of the safety of a non-animal stabilized hyaluronic acid (NASHA – Q-Medical, Sweden) in European countries: a retrospective study from 1997 to 2001.
        J Eur Acad Dermatol Venereol. 2004; 18: 422-425