Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4634_Библиотеки_им_академика_М_И_Перельмана
.pdf
30
https://t.me/medicina_free
4 Blue Laser Therapy ofExudative Lesions oftheVocal Folds
Fig. 4.3 Endoscopic view of the larynx 6weeks after surgery showing complete regression of the lesion. Note mild
edema and redness at the site of the surgery which was
treated conservatively with marked improvement
4.1.2.2 Case 2: Right Vocal Fold
Hemorrhagic Polyp
A 68-year-old man presented to the Voice Clinic
(ALH) with history of hoarseness of a few months;
duration. He had no history of phonotrauma,
smoking, or reux disease. His Voice Handicap
Index-10 (VHI-10) score on presentation was 17.
On perceptual evaluation, he had grade 3 dysphonia with grade 2 breathiness, grade 0 asthenia, and
grade 0 strain. On laryngeal examination, he had a
right hemorrhagic vocal fold polyp with incomplete closure of the vocal folds during phonation.
The patient underwent ofce-based blue laser surgery (power 10W. pulse duration 40 ms, pause
time 300 ms) using the contact and non-contact
modes (Fig. 4.4). The author chose a prolonged
pulse duration (40ms instead of 10ms) because
the lesion was large and hemorrhagic. Six weeks
following surgery the patient had marked improvement in his voice quality. His VHI-10 score was 3,
and he had normal voice quality on perceptual
evaluation. Acoustic analysis after surgery showed
minimal change in fundamental frequency (F0
140.25Hz pre-operatively vs. 133.54Hz, postoperatively), but a decrease in jitter (2.8 preoperatively vs. 1.76 postoperatively) and decrease
in shimmer (14.87 pre-operatively vs. 3.28 postoperatively). Similarly, there was a decrease in noiseto-harmonic ratio and voice turbulence index (0.29
vs. 0.12, and 0.045 vs. 0.037, respectively). The
Fig. 4.4 Endoscopic view of the larynx showing a right
hemorrhagic vocal fold polyp. Note blanching of the
lesion when the laser is used in a contact mode
Fig. 4.5 Laryngeal videostroboscopic image showing
complete regression of the lesion 6 weeks after surgery
maximum phonation time increased from 5.72s
pre-operatively to 9.17 s postoperatively. On
laryngeal examination 6 weeks later, he had complete regression of the lesion (Fig.4.5).
4.1.2.3 Case 3: Right Vocal Fold Polyp
A 62-year-old female presented to the Voice
Clinic (ALH) with hoarseness of a few years’
duration. The patient had no symptoms related to
breathing or swallowing and she denied any history of smoking, phonotrauma, reux disease, or
allergy. Her Voice Handicap Index-10 (VHI-10)
score on presentation was 8. On perceptual evaluation, she had grade 1 dysphonia, grade 1 roughness, grade 0 breathiness, and grade 0 strain.
Acoustic analysis showed a fundamental fre-
4.1 Blue Laser Therapy ofVocal Fold Polyps
https://t.me/medicina_free
quency (F0) of 197.88Hz, habitual pitch (HP) of
197.04 Hz, jitter: 1.88, shimmer 7.98, noise-toharmonic ratio (NHR) of 0.14, and voice turbulence index (VTI) of 0.056. Her maximum
phonation time (MPT) was 18.72s. On laryngeal
examination, she had a polyp in the anterior onethird of the musculomembranous portion of the
right vocal fold with a reactive lesion on the opposite vocal fold. The patient underwent ofcebased blue laser therapy for her lesion under local
anesthesia using power 10 W, pulse duration
10ms, and pulse pause 300ms, and 28.3J were
given during the procedure (Figs. 4.6 and 4.7,
Video 4.1). The laser was used in contact and noncontact modes and laser treatment was followed
by a steroid injection in the surgical bed. Three
weeks after the surgery, the patient presented with
marked improvement in her voice quality. Her
VHI-10 score was 0, and perceptual evaluation
revealed a normal voice. Acoustic analysis postoperatively showed an F0 of 151.15Hz, HP of
153.48Hz, jitter of 0.61, shimmer of 2.31, NHR
of 0.11, and VTI of 0.043. Her MPT was 19.08s.
Laryngeal endoscopic examination showed complete regression of the right vocal fold polyp
(Fig.4.8). Laryngeal videostroboscopic examination revealed normal mucosal waves (Video 4.2).
31
Fig. 4.7 Endoscopic view of the larynx during surgery
showing how the glass ber is used to curet the lesion
Fig. 4.6 Endoscopic view of the larynx showing the blue
laser in near-contact mode against the right vocal fold
polyp. (Video 4.1 Laryngeal endoscopic view showing
blue laser therapy of a right vocal fold gelatinous polyp)
(▶ https://doi.org/10.1007/000- an3)
Fig. 4.8 Endoscopic view of the larynx 3 weeks after surgery showing regression of the lesion and complete closure of the vocal folds during phonation. (Video 4.2
Laryngeal examination 3 weeks after surgery showing
complete regression of the lesion with complete closure of
the vocal folds and restoration of the normal mucosal
waves) (▶ https://doi.org/10.1007/000- amx)
4.1.2.4 Case 4: Left Vocal Fold
Hemorrhagic Polyp
A 57-year-old male presented to the Voice Clinic
(ALH) with hoarseness of a few months’ duration associated with voice overuse. The patient
was a smoker but denied any history of reux disease or allergy. His Voice Handicap Index (VHI-
10) score was 8; and on perceptual evaluation, he
32
https://t.me/medicina_free
4 Blue Laser Therapy ofExudative Lesions oftheVocal Folds
had grade 2 dysphonia with grade 2 roughness
and grade 1 breathiness. Acoustic analysis
showed a fundamental frequency (F0) of
92.41Hz, habitual pitch of 93.64Hz, jitter: 0.84,
shimmer: 3.76, noise-to-harmonic ratio (NHR):
0.12, voice turbulence index (VTI): 0.042, and
maximum phonation time (MPT): 12.09 s.
Laryngeal examination using the exible nasopharyngoscope showed a left vocal fold hemorrhagic polyp with a reactive lesion on the opposite
side. The patient underwent ofce-based blue
laser therapy using the contact and non-contact
modes and he received a total of 72.2J (Fig.4.9,
Video 4.3). Laser therapy was followed by submucosal vocal fold steroid injection using dexamethasone. The procedure was tolerated well.
The patient presented for follow-up 4weeks following surgery with improvement in his voice
quality. The VHI-10 score was 0 and perceptual
evaluation revealed grade 0, for dysphonia.
Acoustic analysis showed an F0 of 99.96Hz, HP
of 97.92Hz, jitter: 0.44, shimmer: 2.28, NHR of
0.13, VTI of 0.055, and MPT of 23.46 s.
Laryngeal endoscopic examination showed complete regression of the left vocal fold hemor-
Fig. 4.10 Laryngeal stroboscopic view during the open
phase of a glottic cycle showing complete disappearance
of the lesion 4weeks after surgery. Note mild edema and
erythema at the surgical bed. (Video 4.4 Follow-up laryngeal videostroboscopic examination showing complete
regression of the lesion with complete closure of the vocal
folds during phonation. Note mild hyperemia and edema
on the supercial surface of the left vocal fold)
(▶ https://doi.org/10.1007/000- amz)
rhagic polyp with mild edema and redness at the
surgical site (Fig. 4.10). Laryngeal
videostroboscopic examination revealed normal
mucosal waves (Video 4.4).
Fig. 4.9 Endoscopic view showing blanching of the
lesion when the blue laser is used in a non-contact mode.
(Video 4.3 Laryngeal endoscopic view showing blue laser
beam targeting a left vocal fold hemorrhagic polyp. Note
blanching of the lesion during therapy)
(▶ https://doi.org/10.1007/000- amy)
4.1.2.5 Case 5: Right Vocal Fold
Hemorrhagic Polyp
A 72-year-old male, professional voice user
(teacher) presented to the Voice Clinic (ALH) with
hoarseness of a few months’ duration. He denied
history of smoking, phonotrauma, allergy, or
reux. His Voice Handicap Index (VHI-10) score
was 4, and on perceptual evaluation, he had grade
1 dysphonia, grade 1 roughness, grade 0 breathiness and strain. Acoustic analysis showed a fundamental frequency (F0) of 105.96Hz, habitual pitch
(HP) of 118.47Hz, jitter of 1.18, shimmer of 3.9,
noise-to-harmonic ratio (NHR) of 0.13, voice turbulence index (VTI) of 0.03, and maximum phonation time (MPT) of 11.04 s. Laryngeal
examination using the exible nasopharyngoscope
showed a right vocal fold polyp with a reactive
4.1 Blue Laser Therapy ofVocal Fold Polyps
https://t.me/medicina_free
33
Fig. 4.11 Endoscopic view of the larynx showing the
blue laser glass ber in contact mode against the vocal
fold polyp. (Video 4.5 Blue laser therapy of a right vocal
fold polyp. The laser is used in near-contact and contact
mode. The laser therapy was followed by removal of the
surgical debris using a cup forceps and by submucosal
injection of dexamethasone solution)
(▶ https://doi.org/10.1007/000- an0)
Fig. 4.12 Endoscopic view of the larynx showing the
cup forceps abutting the right vocal fold free edge before
grasping the lased vocal fold polyp
Fig. 4.13 Endoscopic view of the larynx showing the
cup forceps retrieving the right vocal fold polyp treated
with the blue laser
Fig. 4.14 Endoscopic view showing the needle tip (25
gauge) inserted submucosally in the right vocal fold. Note
the ballooning of the vocal fold cover following the injection of dexamethasone
The procedure was tolerated well. Three weeks
after surgery, the patient had a normal voice and a
drop in his VHI-10 score to 0. Acoustic analysis
lesion on the opposite side. The patient underwent
ofce-based blue laser therapy for his lesion under
local anesthesia and received a total of 44J (power
10W, pulse duration 10ms, pulse pause 300ms)
(Fig.4.11). Laser therapy was followed by removal
of the surgical debris using a cup forceps and by a
submucosal injection of dexamethasone into both
vocal folds (Figs.4.12, 4.13, and 4.14, Video 4.5).
revealed an F0 of 105.03Hz, HP of 104.09Hz, jit-
ter of 1.11, shimmer: 2.81, NHR of 0.15, VTI of
0.04. His MPT was almost unchanged (10.99s).
Laryngeal endoscopic examination showed com-
plete regression of the right vocal fold polyp
(Fig. 4.15). Laryngeal videostroboscopic exami-
nation revealed normal mucosal waves (Video
4.6).
34
https://t.me/medicina_free
Fig. 4.15 Laryngeal stroboscopic view 3 weeks following surgery showing complete regression of the lesion.
(Video 4.6 Laryngeal videostroboscopic examination 3
weeks after surgery showing complete regression of the
lesion with restoration of the normal mucosal waves during phonation) (▶ https://doi.org/10.1007/000- an1)
4 Blue Laser Therapy ofExudative Lesions oftheVocal Folds
4.1.2.6 Case 6: Right Vocal Fold
Hemorrhagic Polyp
withSubmucosal Bleeding
A 34-year-old female patient presented to the
Voice Clinic (ALH) with hoarseness of a few
months’ duration associated with voice abuse.
The patient was a smoker but had no history of
allergy or reux disease. Her Voice Handicap
Index (VHI-10) score was 33. On perceptual
evaluation, she had grade 2 dysphonia, grade 2
roughness, grade 1 breathiness, grade 1 asthenia,
grade 0 strain. Acoustic analysis showed a fundamental frequency (F0) of 165.14 Hz, habitual
pitch of 164.11 Hz, jitter of 1.16, shimmer of
1.96, noise-to-harmonic ratio (NHR) of 0.14, and
voice turbulence index (VTI) of 0.023. Her maximum phonation time (MPT) was 15.63 s.
Laryngeal examination using the exible nasopharyngoscope showed a large hemorrhagic
polyp on the right vocal fold with submucosal
hemorrhage. There was also mild edema at the
free edge of the left vocal fold. The patient underwent ofce-based blue laser therapy for the right
vocal fold polyp under local anesthesia using the
400nm glass ber, power 10 W, pulse duration
40 ms, and pulse pause 300 ms. The patient
received in total of 71.7J.The surgeon chose the
40 ms pulse duration because of the extensive
Fig. 4.16 Endoscopic view of the larynx showing the
blue laser glass ber directed at the right vocal fold polyp.
Note blanching of the lesion. (Video 4.7 Endoscopic view
of the larynx showing blue laser therapy of a large right
vocal fold hemorrhagic polyp. Note the submucosal hem-
orrhage that involves the whole length of the right vocal
fold) (▶ https://doi.org/10.1007/000- an2)
Fig. 4.17 Endoscopic view 5 weeks after the surgery
showing almost complete regression of the hemorrhagic
polyp with residual edema at the site of the surgery.
(Video 4.8 Blue laser therapy of bilateral Reinke’s edema.
The laser is used in contact and non-contact mode)
(▶ https://doi.org/10.1007/000- amw)
size of the lesion and its hemorrhagic nature
(Fig.4.16), (Video 4.7). Laser therapy was fol-
lowed by a submucosal injection of dexametha-
sone into both vocal folds. The procedure was
tolerated well. Five weeks post-surgery, the
patient presented with marked improvement in
her voice and a drop in her VHI-10 score to 8.
Perceptual evaluation revealed a normal voice
despite residual edema and yellowish
discoloration at the site of the surgery (Fig.4.17).
4.2 Blue Laser Therapy ofReinke’s Edema
https://t.me/medicina_free
35
Acoustic analysis showed a mild increase in F0
to 176.1Hz, a decrease in jitter to 0.28, and in
NHR to 0.13.
4.2 Blue Laser Therapy
ofReinke’s Edema
4.2.1 Introduction
Reinke’s edema is a benign condition of the vocal
folds characterized by mucoid, gelatinous uid in
the supercial layer of the lamina propria. It is
more common in women than men with smoking
being the main risk factor [3, 11]. In a review of
the histologic changes and risk factors of 125
patients with Reinke’s edema, Marcotullio etal.
reported an association between the duration and
quantity of cigarette smoking and the severity of
histologic changes [33]. Laryngopharyngeal
reux disease also is considered an etiologic factor in Reinke’s edema. In a review on laryngopharyngeal signs in patients with
laryngopharyngeal reux (LPR), Powell and
Cocks reported a higher prevalence of Reinke’s
edema in those with pH-proven pharyngeal
reux. Reinke’s edema among other signs such
as pseudosulcus vocalis was also more prevalent
in patients with symptoms of LPR in comparison
to those with no symptoms of LPR [34]. In
another review on the signicance of LPR in
benign lesions of the vocal folds, Chung etal.
reported a prevalence of LPR in 90% of patients
with Reinke’s edema. The cohort of 110 patients
was investigated using 24-h ambulatory double
pH monitoring [35]. The retrograde movement of
the gastroduodenal contents results in chemical
irritation to the mucosal cover of the vocal folds.
This in turn leads to injury to the endothelial lining of the submucosal capillary vasculature with
subsequent extravasation of uid and edema formation. As a result, there is expansion of the subepithelial space and ballooning of the vocal folds.
Another signicant risk factor for the development of Reinke’s edema is phonotrauma in the
form of voice abuse and/or misuse/overuse. Like
other exudative lesions of the vocal folds,
Reinke’s edema may ensue as a result of phonatory stress. The mechanical trauma to the vocal
folds during phonation leads to an increase in
intra-capillary pressure resulting in exudation of
uid into the Reinke’s space [36].
Patients with Reinke’s edema present with dysphonia often referred to as deepening of the voice.
Airway symptoms such as dyspnea and snoring
also can occur in patients with advanced disease
[37]. Perceptual evaluation reveals low fundamen-
tal frequency described as androphonia in women.
The voice also is perceived in some cases as
breathy and strained [3, 11]. Acoustic analysis
shows a decrease in fundamental frequency (F0)
and phonatory range, and an increase in jitter,
shimmer, and noise-to-harmonic ratio. In a review
of 76 patients with Reinke’s edema, Colizza etal.
reported a mean fundamental frequency of
147.58Hz in females, with a shimmer and jitter of
11.17 and 3.73, respectively. The decrease in F0
and the increase in jitter and shimmer in comparison to the control group were attributed to the
mass effect of the lesion and disease-induced
irregular vibrations of the vocal folds. Another
contributing factor to the change in voice quality
of affected patients is supraglottic constriction
which is often compensatory. The authors also
noted differences in the acoustic analysis values
across different types of Reinke’s edema [38]. On
laryngeal examination, patients with Reinke’s
edema usually present with enlargement of both
vocal folds (which can be asymmetric) and prominence of the submucosal vessels. The outpouching
or swelling can involve the lower and upper lip of
the vocal fold and can extend from the anterior
commissure to the vocal process. Several grading
systems have been suggested based on the morphologic appearance and severity of the disease
[39–41]. Based on Yonekawa’s classication,
patients with type 3 lesions have extensive disease
of the upper and lower lip with signicant narrowing of the glottic lumen [39]. Laryngeal videostroboscopic examination shows an increase in
mucosal waves and phase asymmetry. These signs
are attributed to derangement in collagen ber distribution in the Reinke’s space. Using the picrosirius polarization method on 20 specimens of
vocal folds with Reinke’s edema, Sakae et al.
reported fragmentation and disarrangement of collagen bers that correlated with the severity of the
disease [42]. Other histologic ndings include
36
https://t.me/medicina_free
4 Blue Laser Therapy ofExudative Lesions oftheVocal Folds
thickening of the epithelium and basement membrane, edematous lakes, vessel proliferation, extravascular erythrocytes, hemorrhage, brosis, and
inammatory inltrates. Díaz-Flores etal. reported
activation of CD34+ broblasts in Reinke’s edema
with changes in the density and morphology of
these stromal cells in the vicinity of the edematous
lakes [43]. All the above changes are responsible
for the alteration in vocal fold viscosity and rheologic properties.
Treatment of Reinke’s edema requires a multidisciplinary approach. Behavioral modication
and voice therapy are often the rst line of therapy.
Surgical excision is only advocated in patients
who fail voice therapy and express a need to
improve their voice. Traditionally surgery is performed under general anesthesia and suspension
microlaryngoscopy. After raising a mucosal
microap, the gelatinous substance is either suctioned or removed piecemeal to reduce the vocal
fold mass. Afterward, the redundant mucosa is
trimmed, and the mucosal ap is draped in place
[44–47]. With the advent of endoscopes with
working channels, intralesional injections using
steroids [23, 48] or hyaluronidase [49] have gained
popularity as alternative treatment modalities with
successful outcome. Photoangiolytic lasers also
have been advocated in the management of vocal
fold exudative lesions including Reinke’s edema.
Zeitels etal. reported the use of thulium laser in an
ofce setting in two patients with vocal fold edema
[50]. Mouadeb and Belafsky reported the use of
the pulse dye laser (PDL) in-ofce in a cohort of
47 patients, 10 of whom had Reinke’ edema. Only
20% needed further surgery in the operating room,
but one patient developed stridor following inofce laser therapy [24]. Pitman etal. reviewed the
use of potassium titanyl phosphate (KTP) laser in
the treatment of 7 patients with Reinke’ edema and
reported an increase in the median F0 by 24Hz,
with improvement in all the perceptual evaluation
parameters. There was also a decrease in the
median score of the Voice Handicap Index (VHI)
by almost 11 points following surgery [51].
Koszewski et al. reported widening of the frequency range and a drop in percent jitter in 14
patients with Reinke’s edema who underwent photoangiolytic laser therapy in an ofce setting. The
authors stressed the usefulness of in-ofce laryngeal surgery in the management of affected
patients [52]. Hamdan etal. described the use of
thulium laser in a cohort of 11 patients with
Reinke’s edema and reported signicant improvement in the mean VHI-10 score and perceptual
evaluation parameters. Moreover, there was an
increase in the mean F0 by 30Hz [53]. Ghanem
and Hamdan also reported the use of blue laser in
eight patients with Reinke’s edema. Following
ofce-based surgery there was a decrease in the
mean VHI-10 score with partial or complete resolution of the lesion in all subjects. The signicant
increase in F0 by 36Hz was particularly noteworthy [54]. Similar results can be achieved when the
laser is used in the same fashion in the operating
room under general anesthesia.
4.2.2 Case Presentations
4.2.2.1 Case 1: Left Vocal Fold Reinke’s
Edema
A 32-year-old female, smoker, presented to the
Voice Clinic (ALH) with hoarseness of a few
years; duration. The patient had a history of voice
overuse but denied a history of reux disease.
Voice Handicap Index-10 (VHI-10) score on presentation was 32. Perceptual evaluation revealed
grade 3 dysphonia, grade 3 roughness, grade 1
breathiness, grade 0 asthenia, and grade 1 strain.
On laryngeal examination, she had bilateral grade
1 Reinke’s edema (Fig.4.18). The patient underwent ofce-based blue laser therapy for her left
vocal fold Reinke’s edema therapy using the
400nm glass ber with power 10W, pulse duration 40ms, pause time 300ms (Fig.4.19). Four
months following the surgery, the patient reported
improvement in voice quality. Her VHI-10 score
dropped to 1, and on perceptual evaluation she
had grade 1 dysphonia, grade 1 roughness, grade
0 for breathiness, grade 0 asthenia, and grade 0
strain. On acoustic analysis, she had an increase
in her fundamental frequency (146.371 Hz vs.
163.167Hz) and in her habitual pitch (152.288Hz
vs. 169.86Hz). On laryngeal examination, there
was partial regression of the Reinke’s edema
(Fig.4.20).
4.2 Blue Laser Therapy ofReinke’s Edema
https://t.me/medicina_free
Fig. 4.18 Laryngeal endoscopic view using a 70-degree
telescope showing bilateral Reinke’s edema type 1
Fig. 4.19 Endoscopic view showing the blue laser glass
ber aiming at the left vocal fold Reinke’s edema. Note
the dilated vessels submucosally on the superior surface
of the vocal folds
37
4.2.2.2 Case 2: Bilateral Reinke’s Edema
A 60-year-old male presented to the Voice
Clinic (ALH) with hoarseness of a few years’
duration associated with snoring and symptoms
of obstructive sleep apnea. His Voice Handicap
Index-10 (VHI-10) was 16, and his Dyspnea
Index (DI) score was 7. On perceptual evaluation, he had grade 3 dysphonia, grade 3 roughness, grade 1 breathiness, grade 2 asthenia, and
grade 3 strain. Laryngeal exible endoscopy
revealed type 3 Reinke’s edema bilaterally. The
patient underwent ofce-based blue laser therapy mostly for the right vocal fold Reinke’s
edema using the 400 nm glass ber (power
10W, pulse duration 40ms, pause time 300ms)
(Fig.4.21, Video 4.8). On follow-up 4 weeks
after the surgery, the patient had marked
improvement in his voice quality and breathing.
There was a signicant decrease in his VHI-10
score and DI score. On perceptual evaluation,
he had grade 1 dysphonia, grade 1 roughness,
grade 0 breathiness, and grade 0 strain.
Laryngeal examination revealed marked regression in the size of the edema (type 1 Reinke’s
edema on the right and type 2 Reinke’s edema
on the left). His second follow-up 3weeks later
showed almost complete regression on the right
side. The patient was advised to undergo a sec-
Fig. 4.20 Laryngeal view 4weeks after blue laser therapy showing partial regression of the Reinke’s edema in
both vocal folds
Fig. 4.21 Endoscopic view of the blue laser glass ber in
contact mode with the right vocal fold Reinke’s edema.
Note marsupialization of Reinke’s space showing the
gelatinous material (see Video 4.8)
38
https://t.me/medicina_free
4 Blue Laser Therapy ofExudative Lesions oftheVocal Folds
ond session of in-ofce blue laser therapy for
the left side following which there was complete regression of the lesion (Figs. 4.22 and
4.23, Video 4.9). Acoustic analysis showed
increase in the fundamental frequency by
almost 35Hz with a decrease in jitter from 1.95
to 1.00, and in shimmer from 9.37 to 7.47. It is
worth noting that bilateral treatment of Reinke’s
edema remains controversial. Many surgeons
perform it including one of the senior authors
(ALH), while others advocate unilateral treat-
Fig. 4.22 Laryngeal view 6weeks after blue laser therapy for both right and left vocal folds Reinke’s edema
showing complete regression of the lesion bilaterally.
(Video 4.9 Laryngeal videostroboscopic examination
showing almost complete regression of Reinke’s edema
with good closure of the vocal folds during phonation)
(▶ https://doi.org/10.1007/000- an4)
ment, staging the second side as needed, in
nearly all cases including another one of our
senior authors (RTS).
4.2.2.3 Case 3: Bilateral Reinke’s Edema
A 49-year-old female heavy smoker presented to
the Voice Clinic (ALH) with hoarseness of few
years’ duration. Her Voice Handicap Index-10
(VHI=10) score was 10, and on perceptual evaluation she had grade 3 dysphonia, grade 3 roughness, grade 1 breathiness, and grade 1 strain. Her
fundamental frequency was 87.99Hz, and her
habitual pitch (HP) was 122.19 Hz. Laryngeal
endoscopy revealed type 3 Reinke’s edema of
the vocal fold bilaterally. The patient underwent
ofce-based blue laser therapy for both vocal
folds (power 10W, pulse duration 40ms, pulse
pause 300 ms) (Fig. 4.24, Video 4.10). Eight
weeks following surgery, the patient had
improvement in her voice quality and breathing.
Her VHI score dropped markedly, and laryngeal
examination revealed regression in the size of
the lesion (Fig.4.25). Her postoperative F0 and
HP increased to 216.1 and 200.1 Hz,
respectively.
Fig. 4.23 Laryngeal videostroboscopy 6 weeks after
therapy showing complete closure of the vocal folds during phonation (see Video 4.9)
Fig. 4.24 Endoscopic view of the larynx showing the
blue laser glass ber in contact with the Reinke’s edema
of the right vocal fold. (Video 4.10 Laryngeal endoscopic
view showing blue laser therapy of Reinke’s edema. Note
blanching of the lesion during treatment)
(▶ https://doi.org/10.1007/000- an5)
4.2 Blue Laser Therapy of Reinke’s Edema
https://t.me/medicina_free
39
Fig. 4.25 Telescopic view of the vocal folds 8 weeks
after treatment showing complete regression of the
Reinke’s edema bilaterally
4.2.2.4 Case 4: Bilateral Reinke’s Edema
A 66-year-old female presented to the Voice
Clinic (ALH) with a history of hoarseness and
dyspnea of 6months’ duration associated with
heavy smoking and reux disease that had been
treated erratically. Her voice symptoms were
accompanied by globus sensation, excessive
throat clearing, and dysphagia to solids and liquids. Voice Handicap Index-10 (VHI-10) was
13. Dyspnea Index score was 22. Perceptual
evaluation revealed grade 3 dysphonia with a
score of 3 for roughness, 1 for breathiness, 1 for
asthenia, and 1 for strain. On laryngeal examination, she had type 1 Reinke’s edema on the
right vocal fold and type 3 Reinke’s edema on
the left vocal fold. The patient underwent blue
laser therapy for the left vocal fold Reinke’s
edema in the ofce under local anesthesia using
the 400nm glass ber (power 10W, pulse duration 40ms, pulse pause 300ms) (Fig.4.26). Six
weeks following the surgery, the patient reported
marked improvement in voice quality. VHI-10
score decreased to 7. On perceptual evaluation
she had grade 1 dysphonia, grade 1 roughness,
grade 0 breathiness, and grade 0 strain.
Laryngeal examination showed partial regression in size of the Reinke’s edema on the operated side (Fig.4.27). On acoustic analysis, she
Fig. 4.26 Endoscopic view of the Reinke’s edema of the
vocal fold treated with the blue laser in non-contact mode.
(Video 4.11 Blue laser therapy of a right vocal fold mucus
retention cyst. The laser is used in “incision mode,” and
the glass ber is used to incise the wall of the cyst)
(▶ https://doi.org/10.1007/000- an6)
Fig. 4.27 Laryngeal examination 6weeks later showing
partial regression of the Reinke’s edema of the left vocal
fold
had an increase in her F0 and Habitual pitch by
28 and 13 Hz, respectively. There was also a
decrease in the noise-to-harmonic ratio and
voice-turbulence index. The patient also
reported improvement in her dyspnea, The
Dyspnea Index dropped to 7. Voice therapy and
smoking cessation were advised.
Соседние файлы в папке Библиотека им академика М.И. Перельмана