Laryngeal Microsurgery For The Treatment of Vocal Nodules and Cysts in Dysphonic Children

 

Research Article Received: March 6, 2019 Accepted after revision: August 5, 2019 Published online: September 19, 2019

Folia Phoniatr Logop DOI: 10.1159/000502477

Laryngeal Microsurgery for the Treatment of Vocal Nodules and Cysts in Dysphonic Children Regina Helena Garcia Martins Dândara Bernardo Siqueira Norimar Hernanes Dias Andrea Cristina Joia Gramuglia Department of Ophthalmology, Otorhinolaryngology, Head and Neck Surgery, Botucatu Medical School, University of Estadual Paulista, Botucatu, Brazil

Keywords Voice disorders · Children · Surgery · Dysphonia

Abstract Introduction: Vocal nodules and cysts are frequent causes of infantile dysphonia. Vocal therapy is the first treatment. Microsurgery has restricted indications, especially for nodules. Objective: To describe our experience with microsurgery for nodules and cysts in children. Methods: Dysphonic children (aged 4–18 years) with the diagnosis of nodules and vocal cysts were initially selected. Of these children, only those were included who had undergone microsurgery. For nodules and cysts, the microsurgery was indicated in cases of failure of vocal therapy and in cases of voice worsening or doubts about the diagnosis. All children were submitted to auditory perceptual vocal analysis and videolaryngostroboscopy (before and after surgery, after 6 months). Surgical outcomes were: total improvement (disappearance of vocal symptoms and of the laryngeal lesions); partial improvement (partial improvement of symptoms and/or maintenance of lesions); no improvement (maintenance or worsening of the symptoms and/or persistence of the lesions). Results: There were 78 children with vocal nodules and 27

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children with vocal cysts. Surgery was indicated for 12 children with vocal nodules (15.4%) and 12 children with cysts (44.4%). Total improvement registered for nodules and cysts was 75 and 83.4%, respectively. Partial improvement for both lesions was 25 and 16.6%, respectively. Conclusion:   The best outcome for laryngeal microsurgery in dysphonic children was for vocal cysts. So, we encourage e ncourage laryngologists for this conduct in vocal cysts. The success of microsurgery for vocal nodules was lower, and in these cases voice therapy seems to be the best treatment. © 2019 S. Karger AG, Basel

Introduction

Dysphonia in children is commonly caused by vocal cord nodules (38–78%) and vocal cysts (15–21%) [1–4]. A vocal nodule (Fig. 1) is associated with inadequate vocal habits and vocal abuse, in which frequent traumatic collision of the vocal folds results in injury to the epithelium and superficial layers of the lamina propria [5]. The vocal nodule is more prevalent in boys and is rarely diagnosed in adult men, due to the natural reabsorption of the lesion after puberty [5, 6]. Of the 91 adolescents of both genders Dr. Regina Helena Garcia Martins Department of Ophthalmology, Otorhinolaryngology, Head and Neck Surgery  Botucatu Medical School, University of Estadual Paulista Distrito de Rubião Junior s/n, Botucatu, SP 18618-970 (Brazil) E-Mail rmartins @ fmb.unesp.br

 

  e   n    i    l   n   o   e    l    b   a    l    i   a   v   a     n   o    i   s   r   e   v   r   o    l   o    C

  e   n    i    l   n   o   e    l    b   a    l    i   a   v   a     n   o    i   s   r   e   v   r   o    l   o    C

Fig. 1. Bilateral vocal nodules (arrows).

Fig. 2. Vocal cyst in right vocal fold (arrow).

Table 1. Laryngeal diagnosis and sex

Table 2. Laryngeal diagnosis, mean age (±SD)

Lary La ryng ngea eall dia diagn gnos osis is Bo Boys ys,, n (  (% %)

Girls, n (  (% %)

Total, n (%)

Vocal nodules Vocal cyst

55 (52.38) 15 (14.29)

23 (21.90) 12 (11.43)

78 (72.28) 27 (25.71)

Total

70 (66.67)

35 (33.33)

105 (100.00)

with the diagnoses of vocal nodules in childhood called by De Bodt et al. [6] for a new evaluation after adolescence, only 8% of the boys persisted with vocal symptoms, and 7% remained with structural abnormalities at videolaryngoscopy. Voice therapy is the first treatment for vocal nodules; however, few studies detail the techniques, number of sessions or duration of treatment [6]. The treatment is long and requires changes in vocal habits, which may result in discouraging and abandonment of the treatment. Microsurgery for vocal nodules in children is reserved to special conditions such as dubious diagnoses, complete failure after voice therapy or significant worsening of vocal symptoms [7, 8]. Epidermal vocal cysts (Fig. 2) are the second sec ond most frequent cause of infantile dysphonia. They correspond to an invagination of epithelial cells in the subepithelial plane of the mucosa of the vocal folds [9–11]. The treatment of vocal cysts in children is also controversial among the authors, and voice therapy is not always effective [9– 12]. 2

Folia Phoniatr Logop DOI: 10.1159/000502477

and sex

Laryngeal diagnosis

Age according to sex, years boys girls

 p value

Vocal nodules Vocal cyst

9.69±2.36 10.53±2.80

0.842 0.141

9.70±2.57 12.50±3.92

Table 3. Laryngeal diagnosis and microsurgery 

Laryngeal di diagnosis Vocal nodules Vocal cyst Total

Microsurgery, n (%) 12/78 (15.38) 12/27 (44.44) 24/105 (22.85)

The objective of this study was to present our experience with laryngeal microsurgery for vocal nodules and cysts in children. Methods

This study was approved by the Internal Review Board of our University (protocol No. 59230016.5.0000.5411). Dysphonic children aged 4–18 years were selected who were seen at the Voice Disorders Outpatient Clinic of the Otorhinolaryngology Sector of the University between January 2012 and No-

Martins/Siqueira/Dias/Gramuglia

 

Table 4. Mean of auditory

perceptual vocal analysis (GRBASI scale) in the pre- and postsurgery periods and la-

ryngeal lesion Laryngeal lesion Vocal nodules Vocal cysts

G pre

post

R pre

2.0 1.87

1.3 1.0

1.7 1.62

*

*

post

B pre

1.1 0.62

1.5 1.50

post

A pre post

S pr e

post

I pre post

1.1 0.87

0 0 0.12 0

1.0 0.62

0.3 0.25

0.9 0.3 0.50 0.37

*

 p  p < 0.001.

 vember 2017. 2017. Inclusion Inclusion criteria: children with the diagnoses diagnoses of vovocal nodules and cyst, who had undergone microsurgery. Exclusion criteria: children who did not cooperate with the exam, who did not attend the follow-up or who attended voice therapy in an inconsistent or irregular condition. In order to evaluate the results of the surgery (outcome), we analyzed the vocal symptoms, auditory-perceptual vocal parameters (GRBASI scale; G –degree of hoarseness; R – roughness; B – breathlessness; A – asthenia; S – strain; I – instability), acoustic vocal parameters, videolaryngostroboscopy and the size of the lesions (mm 2), based on the area measurements (length × width; ImageJ software). The size of the lesions was analyzed by 2 blinded reviewers. Children and parents were asked about vocal symptoms. The results of pre- and postsurgery vocal parameters and videolaryngostroboscopies were analyzed and compared by 3 blinded qualified speech therapists to the pre- and poststatus. The surgical results were divided into 3 outcomes: total im provement – complete disappearance of vocal symptoms and lesions;  partial improvement  –   – partial improvement of the symptoms and/or maintenance of laryngeal lesions; no improvement – maintenance or worsening of vocal symptoms and/or persistence of laryngeal lesions. All children had 20–24 weekly sessions of voice therapy before and after the surgery. Initially the vocal therapy programming was discussed and explained to the child and parents. Topics such as normal vocal and respiratory physiology were presented, using appropriate language for children. The impact of voice disorders on vocal function was presented. The vocal therapy itself consisted of exercises in 20–24 individual weekly sessions (once a week) lasting 40–45 min (before and after surgery), using techniques of nasal sound production, vibrating sounds, basal sounds, yawning, sighing, chewing and production of fricative sounds. Parental participation in speech therapy sessions was always encouraged. Parents were encouraged to perform the same exercises with their children at home during daily activities.

The laryngeal diagnoses of dysphonia were confirmed by videolaryngostroboscopy conducted with a rigid telescope (8 mm in diameter, 70°, Asap, Germany) or flexible nasofibroscope (3.5 mm, Olympus, Japan) coupled to a videolaryngoscopy image capture system (XE-50, Eco V 50W X-TFT/USB, ILO Electronic GmbH, Carl Zeiss, Germany; Asap microcamera, Germany; professional lapel microphone Leson, Brazil) and a stroboscope system (EndoStroboscope, Atmos, MedizinTechnik GmbH & Co. KG, Germany).

Surgical Treatment for Vocal Nodules and Cysts

The auditory-perceptual vocal evaluation was performed using u sing the GRBASI scale [13]. Vocal parameters were recorded during spontaneous speech and sustained phonation of the vowel /a/. GRBASI scale results were quantified through a 0–3 intensity score by 3 blinded professionals with experience in voice assessments. There should have been an agreement between at least 2 of them. Statistical analysis compared the difference in age using the Student t  test  test and the difference in categorical variables using the χ 2 test. We set statistical significance at p ≤ 0.05.

Results

Among the 162 dysphonic children seen during the study period, 105 met the inclusion criteria. So, we selected 105 dysphonic children (boys = 70; girls = 35) with the diagnosis of vocal nodules (n = 78; 72.28%) and cysts (n = 27; 25.71%) (Table 1). The mean age (±SD) was 10.5 (±3.0) years (minimum 5; maximum 18 years). The mean age was discretely lower for nodules, without statistical difference between the sexes (Table 2). Vocal nodules were diagnosed in 78 children of whom 12 underwent surgery (15.38%). The youngest child undergoing microsurgery for vocal nodule was 9 years old. Of the 27 children diagnosed with cysts, 12 underwent surgery (44.44%), all with epidermal cysts (Table 3). The youngest child was 7 years old. For vocal nodules and cysts, the microsurgery was indicated in cases of worsening or no improvement of symptoms after voice therapy. Tables 4 and 5 list the auditory-perceptual and acoustic vocal analysis in 2 moments (before and after surgery) for both lesions, respectively. There was improvement of the auditory perceptual parameters after surgery, especially the G parameter for nodules and the R parameter for cysts (Table 4). There was improvement of the acoustic parameters in both lesions after surgery except for f0 in the nodules (Table 5).

Folia Phoniatr Logop DOI: 10.1159/000502477

3

 

Table 5. Acoustic

parameters (median; SD) of pre- and postsur-

Table 6. Outcomes after surgery for vocal nodules and cysts

gery assessments Parameters

Moments

Vocal nodules

Vocal cysts

Laryngeal lesion

f0, Hz

pre post  p v  vaalue

220.50 (6.49) 222.33 (14.13) 0.577

2.17.00 (3.44) 2.28.33 (5.94)