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Nayla Matar 1, Marc Remacle 2, Vincent Bachy 2, Georges Lawson 2 , Antoine Giovanni 3, Vinciane Lejoly-Devuyst 2, Thierry Legou4

1Hôtel Dieu de France, Bellevue Medical Center, Saint Joseph University. Beirut, Lebanon2 University hospital of Louvain at Mont-Godinne. Yvoir, Belgium

3 La Timone University Hospital. Marseille, France4 Laboratoire Parole et Langage. CNRS – Université de Provence. Aix-en-Provence, France.

Erwin WurmDisziplin der Subjektivität2006-2011

� Numerous options have been introduced for the treatment of glottal insufficiency

� Isshiki’s type I medialization thyroplasty is the main strategy in laryngeal framework surgery

� Drawback� Cannot be modified postoperatively without a revision surgery despite the various types of implants

� In order to prevent revision thyroplasty surgeons must have adequate tools to choose the appropriate size of the implant during MT

� Relying on subjective per operative assessment of the voice quality during MT, <50% of the surgeon’s can expect postoperative outcomes.

� SGP can be measured easily and has been linked to vocal efficiency

� SGP is statistically higher in dysphonic patients than in healthy subjects

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� Till now, intraoperative assessment of the adequacy of glottal closure is based on� Physician’s perception� Patient confort� Glottal gap based on peroperative fibroscopy for assessment of vocal folds edge apposition

� Maximum phonation time (Lundy 2004)� Real time objective measurement of SGP could contribute to the choice of the implant’s size (IS) in medialization thyroplasty (MT).

� Assess the feasibility of measuring peak direct subglottic pressure (PDSGP) in the setting of MT using the Montgomery implant (MI) in humans

� Study the variation of PDSGP with the variation of MI size

� Prospective study� Inclusion criteria� >18 years� Glottal insufficiency� Thyroplasty Type I + Montgomery implant� Informed consent

� Surgery� Supine position� Light sedation � Local anesthesia (Skin and trachea)

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� Perceptual assessment� Breathy vocal quality assessed by operating surgeon and speech pathologist after asking the patient to sustain the vowel /a/ at a comfortable pitch and amplitude, each time the implant model size was changed

� Glottal Closure assessment� Flexible videoendoscope ENF type VT-2 (Olympus, Lake

Success, NY)� Judgment of glottal closure was subjectively made by the operating surgeon each time the implant model size was changed.

� Real time peak subglottic pressure measurement� Large peripheral venous flexible catheter of 18 GA (BD INSYTE-WTM, NJ, USA) through the cricoithyroid membrane.

� Connected to the oral pressure sensor of the Phonatory Aerodynamic System (PAS, KayPentax, USA) with a perfusion cable.

� Patient was asked to sustain the vowel /a/ 3 times for each implant size at a comfortable pitch and intensity

� The mean value of the PDSGP was recorded.

� Values were recorded with each size of the Montgomery implant model.

� The final implant size was chosen when the perceptual judgment of the patient, surgeon and speech pathologist concurred with the assessment of the glottis gap and the lowest value of the PDSGP.

Patient Gender Age in years

Cause of Glottal insufficiency

PDSGP preimplant in cm H2O

PDSGP post implant in cm H2O

Size of the implant

1 M 57 Extended cordectomy14.97 10.46

122 M 52 Extended cordectomy

23.83 16.9

12

3 M 63 Left vocal fold paralysis14.55 6.91

114 M 40 Left vocal fold paralysis

15.5 14.313

5 F 53 Left vocal fold paralysis10.5 7.5

10

6 F 63 Left vocal fold paralysis12 7.6

8

Mean PDSGP 15.2 10.6SD (PDSGP) 5 4

The difference between PDSGP preimplant and PDSGP postimplant was statistically significant(Wilcoxon signed rank test for paired samples ; p=0.028 )

Patients tolerance of PDSGP measurement was very good

Assess the feasibility of measuring PDSGP in the setting of MT using the Montgomery implant in humansRESULTS: STUDY 1

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Study the variation of PDSGP with the variation of MI size

Males Implant 6 Implant 7 Implant 8 Implant 9 Implant 10

♀ 1 10 9.4 7.6 10.1 12♀ 2 8.8 9.8 12.1 NT NT♀ 3 10.9 11.9 16.24 NT NT

Study the variation of PDSGP with the variation of MI size

Females Implant 8 Implant 9 Implant 10 Implant 11 Implant 12 Implant 13

♂ 1 25.4 21.0 22.5 24.4 27.5 NT♂ 2 21.8 16.7 23 20.6 20.2 19.3

� In the surgical setting of MT the invasive nature of the placement of the transducer for the measure of SGP does not apply

� We used peak subglottic pressure, because according to Ketelslagers et al, under normal pitch and intensity conditions, there is a significant difference of the peak SGP between patients with vocal fold pathology and controls.

� We observed that the PDSGP diminished when the glottis area was reduced by the approximation of the vocal fold until an optimal position was reached. After this position, the augmentation of the size on the MI implant produced an increase of the PDSGP.

� DPSG was measured in the supine position under sedation. � This could modify its value compared to the pre/postoperative measures.

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� Per operative measurement of PDSGP is feasible and it does not induce patient related side effects

� The use of the Phonatory Aerodynamic System did not seem inconvenient or bulky

� DPSGP will give an intraoperative objective real time assessment of vocal efficiency

� However, more patients should be included in the study to confirm its utility

� 1. Dedo HH. Injection and removal of Teflon for unilateral vocal cord paralysis. Ann Otol Rhinol Laryngol 1992; 101:81–86� 2. Song PC, Sung CK, Franco RA. Voice outcomes after endoscopic injection laryngoplasty with hyaluronic acid stabilized gel. Laryngoscope 2010; 120 Suppl 4:S199� 3. Rosen CA, Gartner-Schmidt J, Casiano R, Anderson TD, Johnson F, Reussner L, Remacle M, Sataloff RT, Abitbol J, Shaw G, Archer S, McWhorter A. Vocal fold augmentation with calcium hydroxylapatite (CaHA). Otolaryngol Head Neck Surg 2007; 136(2):198-204� 4. Isshiki N, Morita H, Okamura H, HiramotoM. Thyroplasty as a new phonosurgical technique. Acta Otolaryngol 1974; 78: 451–457� 5. Harries ML, Morrison M. Short-term results of laryngeal framework surgery— thyroplasty type 1: a pilot study. J Otolaryngol 1995; 24:281–287� 6. Friedrich G. Titanium vocal fold medializing implant: introducing a novel implant system for external vocal fold medialization. Ann Otol Rhinol Laryngol 1999; 108:79–86� 7. Montgomery WW, Blaugrund SM, Varvares MA. “Thyroplasty: a new approach” in Annals of otology rhinology and laryngology 1993; 102: 571-579� 8. Isshiki N, Tanabe M, Sawada M. Arytenoid adduction for unilateral vocal cord paralysis. Arch Otolaryngol 1978; 104:555–558� 9. Zeitels SM, Hochman I, Hillman RE. Adduction arytenopexy: a new procedure for paralytic dysphonia with implications for implant medialization. Ann Oto Rhinol Laryngol 1998; 107: 2–24� 10. Paniello RC. Laryngeal reinnervation. Otolaryngol Clin North Am. 2004; 37(1):161-81.

� 11. Lundy D, Casiano R, Xue JW. Can Maximum Phonation Time Predict Voice Outcome after Thyroplasty Type I? Laryngoscope 2004; 114: 1447-1454� 12. Hirano M. Clinical examination of voice. In: Arnold GE, Winckel F, Wyke BD eds Disorders of human communication. Springer, Berlin Heidelberg New York 1981; 36–41� 13. Giovanni A, Demolin D, Heim C, Triglia J. Estimated subglottic pressure in normal and dysphonic subjects. Ann Otol Rhinol Laryngol 2000; 109:500–504� 14. Hartl DM, Hans S, Vaissière J, et al. Objective voice quality analysis before and after onset of unilateral vocal fold paralysis. J Voice 2001; 15:351–361� 15. Yu P, Ouaknine M, Revis J, Giovanni A. Objective voice analysis for dysphonic patients: a multiparametric protocol including acoustic and aerodynamic measurements. J Voice 2001; 15:529–542� 16. Hartl DA, Hans S, Vaissière J, Brasnu DA Objective acoustic and aerodynamic measures of breathiness in paralytic dysphonia. Eur Arch Otorhinolaryngol 2003; 260:175–182� 17. Ketelslagers K, De Bodt MS, Wuyts FL, Van de Heyning P. Relevance of subglottic pressure in normal and dysphonic patients. Eur Arch Otorhinolaryngol 2007; 264:519–523� 18. Jiang J, Chen HJ, Stern J, Salomon NP.Vocal efficiency measurements in subjects with vocal polyps and nodules: A preliminary report. Ann Otol Rhinol Laryngol 2004; 113: 277-282

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� Intravenous dosages of an opioid for pain control (Remifentanyl).

� A benzioadazepam (Midazolam) as well as a short acting hypnotic agent (Propofol) were used for amnesic/anxiolytic effect.

� A synthetic anticholinergic agent (Glycopyrrolate) was used to decrease salivary secretion.

� Local injection of analgesic (lidocaine 1%, epinephrine1/200000) was used as needed to control pain.