Phonosurgery after endoscopic cordectomies. II. Delayed medialization techniques for major glottic incompetence after total and extended resections

Abstract

Major glottic incompetence is often encountered after total (Type IV) and extended (Type V) cordectomies and is responsible for poor vocal outcome. Even though the vast majority of patients do not complain of significant limitations in daily life, a selected number of them eventually require some sort of phonosurgical treatment in order to improve voice quality. Different techniques have been described in the literature to ameliorate long-term vocal outcome. The aim of the present report was to retrospectively describe our experience in this challenging clinical scenario. Between April 1999 and March 2005, 24 patients previously treated by Type IV-V endoscopic cordectomies for T1 and T2 glottic cancer presented unsatisfactory vocal outcome in spite of intensive speech therapy and therefore underwent some form of phonosurgical treatment at our Department after at least 12 months without evidence of local-regional recurrence. Patients were treated by medialization thyroplasty with a Montgomery System Implant (two cases), Gore-Tex strips (16 cases), medialization thyroplasty with Gore-Tex associated with anterior commissure laryngoplasty (three cases), and augmentation with Vox Implant injection (three cases). Nineteen patients had comprehensive evaluation by videolaryngoscopic examination and subjective, perceptual, and objective voice analysis both in the pre-phonosurgical treatment period and after at least 12 months. Comparison of pre- and postoperative videolaryngoscopic findings revealed improved glottic closure in 74% of patients. Comparison between the pre- and postoperative subjective, perceptual, and objective voice analysis by the Wilcoxon matched-pair test showed a statistically significant improvement from a Voice Handicap Index mean value of 46 (preoperative) to 21 (postoperative); an improvement for each parameter of the GRBAS scale with statistically significant differences for G, B, A, and S, while R showed only an improving trend; and statistically significant improvement in the mean values of Jitter, Shimmer, Noise to Harmonic Ratio, and Maximum Phonation Time. In conclusion, the different delayed phonosurgical procedures herein used demonstrate the possibility to improve vocal outcomes after total and extended cordectomies in selected and highly motivated patients that have not achieved satisfactory performance after prolonged and intensive speech therapy.