ENT Masthead
February 2014 

  In This Issue 

In-Office Treatment of Radiation Fibrosis of True Vocal Folds
About Dr. Halstead

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March 2014:
Surgery for Hyperparathyroidism

April 2014:
Dysphagia Due to Late Radiation Induced Fibrosis

May 2014:
Evaluation of Sleep Disordered Breathing in Children  

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Hope you are all staying warm this winter! Our February e-Update brings you Lucinda A. Halstead, M.D. with in-office options for improving voice quality after treatment of laryngeal cancer.
 
More information on Dr. Halstead follows the article below and is on our website. 
Please feel free to contact us with feedback or questions about the E-Udate articles, your patients, or any other ENT issue at entupdate@musc.edu. Many thanks for your continued interest and support. 
 

 

Paul R. Lambert, MD

Professor and Chair

Lucinda A. Halstead, M.D. - Associate Professor; Medical Director, Evelyn Trammell Institute for Voice and Swallowing, MUSC
In-Office Treatment of Radiation Fibrosis of True Vocal Folds    

While treatment of laryngeal cancers is very successful, vocal outcomes can vary from outstanding to awful with both surgery and XRT. Treatment of laryngeal cancers varies based on the size and location of the lesion. For smaller lesions, treatment with radiation therapy versus excision depends on many factors including institutional biases, continued smoking, size and location of the lesion, patient's overall medical condition, and patient preference.

Since eradicating cancer is the primary focus of otolaryngologists, radiation oncologists and oncologists, the quality of a patient's voice after treatment is often not investigated at the completion of treatment or during follow up. A group of patients that can be easily improved are those with post XRT dysphonia, whose voices are mildly to moderately impaired. In these cases, the predominant laryngeal finding is fibrosis of the laryngeal structures, especially the cover and superficial lamina propria of the true vocal folds which results in a decreased mucosal wave. Laryngoscopic appearance includes dilation of vessels along the superior surface of the TVFs, vascular ectasias along striking zone of the TVFs, and decreased mucosal waves.

Typical radiation fibrosis changes of the vocal folds- atrophy/
stiffness, vascular ectasias on striking zone & dilated vessels on superior surface
Visible light lasers, such as the Pulse Dye and KTP, are commonly used to treat cutaneous scars and cutaneous vascular lesions such as port wine stains by dermatologists and facial plastic surgeons. The collagen remodeling that occurs in this laser-tissue interaction is thought to be due to the selective photothermolysis of blood vessels. This results in a reduction of scar-related angiogenesis and increased pliability of the tissue. In 2008, Woo and his colleagues applied this principle to a wide range of TVF scarring, including radiation fibrosis that was 2-4 years post XRT, with good voice improvement by the Voice Handicap Index, stroboscopy and patient self-report.1 Additionally in 2010, they summarized the new literature on laser scar remodeling in the animal model which shows the development of a sub-basement membrane cleavage plane that is created by the laser energy which can improve the pliability of the superficial lamina propria. This, as well as up-regulation of proteins which may actively modulate continued fibrosis, additionally supports the use of visible light lasers in vocal fold scarring.2 They also note that the fiberoptic technology required to deliver the laser energy is well suited for in-office surgery under topical anesthesia.

Steroid injection has also been found to be beneficial in ameliorating TVF scarring from radiation fibrosis. Mortensen's extensive review of steroid injection concluded that this treatment, especially in the in-office surgical setting, can greatly improve voice. The only caveat is to avoid the use of triamcinalone in TVF injection due to the potential formation of a white plaque on the cover of the vocal fold from the milky white suspension. Although it has not been shown to affect the pliability of the vocal fold, it can easily be mistaken for leukoplakia on laryngeal examination. Methylprednisolone or dexamethasone are most commonly used for this injection in order to avoid this side effect.3 Again the suitability of this procedure for in-office surgery was noted.

I most commonly use a combination of both KTP and steroid injection to treat radiation fibrosis, usually three treatments approximately one month apart. The amount used of each modality depends on the amount of scarring and vascularity present. The majority of patients are treated in the office under topical anesthesia. Patient satisfaction is very high. When operating on these patients, it is important to be aware of the susceptibility of these irradiated larynges to fungal laryngitis, even utilizing laser alone. Additionally, it is critical to monitor the symmetry of the mucosal waves of the vocal folds. Usually, the vibration between the vocal folds is asymmetric at the beginning of the procedure due to variation in the fibrosis of each fold. It is important to attempt to adjust the treatment of each fold so that vibratory symmetry is improved. The voice will be worse with dramatically asymmetric vocal waves than with one non-vibratory fold and one with a good mucosal wave.

XRT changes pre treatment
XRT changes post laser & injection - good restoration of
vibratory symmetry
Treatment of very dense scarring due to surgical removal of tissue or to XRT will require operative intervention under anesthesia. Procedures such as fat implantation into the superficial lamina propria via Gray's minithyrotomy or microflap can then be used, again with the caveat that the irradiated larynx is more prone to complications such as infection, cartilage fracture, tissue renting and bleeding. However, utilizing the in-office technique to reduce scarring can better prepare the vocal folds for such procedures.

 

    

Lucinda A. Halstead , M.D.

Associate Professor; Medical Director, Evelyn Trammell Institute for Voice and Swallowing       
Medical University of South Carolina
REFERENCES
  1. Melissa M. Mortensen, MD; Peak Woo, MD; Chandra Ivey, MD; Chandler Thompson, PhD; Linda Carroll, PhD; Kenneth Altman, MD, PhD. The Use of the Pulse Dye Laser in the Treatment of Vocal Fold Scar: A Preliminary Study. Laryngoscope. 2008; 118(10):1884-8.

  2. Neil Prufer, MD; Peak Woo, MD; Kenneth W. Altman. Pulse Dye and Other Laser Treatments for Vocal Scar. Current Opinion in Otolaryngology & Head and Neck Surgery. 2010; 18:492-497

  3. Melissa M. Mortensen, MD. Laryngeal Steroid Injection for Vocal Fold Scar. Curr Opin Otolaryngol Head Neck Surg. 2010; 18(6):492-7.
About Dr. Halstead... 
 

Lucinda Halstead, M.D. 

 Associate Professor; Medical Director, Evelyn Trammell Institute for Voice
and Swallowing
M.D.: George Washington University
Residency: Tufts/Boston University Program

Special interest:

Laryngology, Medical and surgical care of the voice, Pediatric otolaryngology, Pediatric and adult airway disorders,
Head and neck surgery

 

Medical University of South Carolina Department of Otolaryngology - Head & Neck Surgery

135 Rutledge Avenue, MSC 550, Charleston, SC 29425|Phone: 843.792.8299|Website: ENT.musc.edu| 2014