Vocal fold scars: current concepts and future directions. Consensus report of the phonosurgery committee of the European laryngological society

Abstract

Scarring of the vocal folds leads to a deterioration of the highly complex micro-structure with consecutively impaired vibratory pattern and glottic insufficiency. The resulting dysphonia is predominantly characterized by a reduced vocal capacity. Despite the considerable progress in understanding of the underlying pathophysiology, the treatment of scarred vocal folds is still an unresolved chapter in laryngology and phonosurgery. Essential for a successful treatment is an individual, multi-dimensional concept that comprises the whole armamentarium of surgical and non-surgical (i.p. voice therapy) modalities. An ideal approach would be to soften the scar, because the reduced pliability and consequently the increased vibratory rigidity impede the easiness of vibration. The chosen phonosurgical method is determined by the main clinical feature: Medialization techniques for the treatment of glottic gap, or epithelium freeing techniques for improvement of vibration characteristics often combined with injection augmentation or implantation. In severe cases, buccal mucosa grafting can be an option. New developments, include treatment with anxiolytic lasers, laser technology with ultrafine excision/ablation properties avoiding coagulation (Picosecond infrared laser, PIRL), or techniques of tissue engineering. However, despite the promising results by in vitro experiments, animal studies and first clinical trials, the step into clinical routine application has yet to be taken.

Tissue engineering-based therapeutic strategies for vocal fold repair and regeneration

“…[39] Medialization thyroplasty may be used to repair glottal insuffiency without directly contacting the lamina propria. [40] In addition, Hoy et al described the use of an ultra-fast laser for ablation vocal fold scar tissue. [41] Welham et al investigated the use of surgical treatments for vocal fold scar in a prospective clinical study, where they found that the thyroplasty and graft implantation methods resulted in reduced vocal handicap scores of patients with vocal fold scar, but no improvement in other assessment measures.…”

“…Teflon was historically used as a more permanent material for vocal fold augmentation, but has been associated with undesirable foreign-body reactions. [40] More commonly used materials for injection for vocal fold medialization include Cymetra (collagen-based), Radiesse (calcium hydroxyapatite), and autologous fat. [40] Sataloff described autologous fat as an effective implantation for improving mucosal wave in patients with severe scar formation.…”

“…[40] More commonly used materials for injection for vocal fold medialization include Cymetra (collagen-based), Radiesse (calcium hydroxyapatite), and autologous fat. [40] Sataloff described autologous fat as an effective implantation for improving mucosal wave in patients with severe scar formation. [36,37] Pitman et al investigated the use of temporalis fascia transplantation for treatment of vocal fold scar and sulcus in a group of 10 patients.…”

A Review of Hyaluronic Acid and Hyaluronic Acid-based Hydrogels for Vocal Fold Tissue Engineering

“…Scarring is the downstream manifestation of these injuries, and leads to incomplete mucosal wave formation and eventual dysphonia. 12,38 …”

“…1,38,53 Although improvement in rheological properties and glottal closure are observed post injection, these therapies are more supportive rather than regenerative as they do not repair associated damage with scarring and may also result in long-term complications such as chronic inflammation, implant migration, granuloma formation, and quick resorption times. 38,53 These complications necessitated the development of alternative tissue-engineered treatments for the restoration of normal vocal fold function. HA, because of its non-immunogenicity, non-antigenicity, innate biocompatibility, tunable viscoelastic properties, and ease of modification, is one of the most widely researched vocal fold tissue engineering materials.…”