Gel-Injection Laryngoplasty Overcomes Hypophonia in Parkinson's Disease

Daniel M. Keller, PhD

October 06, 2018

HONG KONG — Vocal cord augmentation by injection laryngoplasty produced both objective and subjective improvements of voice for patients with Parkinson's disease (PD).

Although otolaryngologists have safely injected collagen or gels into the vocal folds for many years to treat atrophy from many causes, the technique has not been widely used in PD. Olga Klepitskaya, MD, University of Colorado Anschutz Medical Campus, Aurora, told Medscape Medical News, "As a neurologist, we don't know about that."

"Our data demonstrated improvement in voice quality due to glottis closure in PD after vocal fold injection augmentation," the researchers conclude. "Further studies of the effect of short- and long-acting vocal fold augmentation are warranted."

Their findings were presented here at the International Congress of Parkinson’s Disease and Movement Disorders 2018.

Speech and voice impairments affect up to 90% of patients with PD, with hypophonia being the major voice disorder and vocal fold atrophy being a major cause. Vocal fold atrophy from disuse, as well as from normal aging, causes glottic insufficiency, resulting in the vocal folds failing to fully approximate; air escapes during vocalization, projection is decreased, and the voice is softer and quieter.

But one day, Klepitskaya said, a patient in her clinic told her that an otolaryngologist "injected something" in his throat, "and I speak better."

So in collaboration with otolaryngologist Matthew Clary, MD, she performed a retrospective and prospective observational study of vocal fold augmentation with carboxymethylcellulose (CMC) gel injection, using objective and subjective measures of the effect on voice and speech among patients with clinically significant voice impairment and glottic insufficiency secondary to idiopathic PD.

Patients (n = 29) received CMC gel injections, expected to last up to 3 months, under direct laryngoscopic visualization. A main objective outcome was the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), performed on deidentified audio recordings by three independent speech therapists blinded to the state of treatment.

Other objective measures were the glottic closure time and supraglottic constrictions. Recordings were made at screening, 1 month later (baseline), and 1 and 5 months after injection.

Patients had a mean age of 72.9 ± 5.87 years with a mean PD duration of 13.0 ± 10.59 years, 25 of the 29 were male, and 27 had had their 1-month follow-up visit by the time of data analysis.

On CAPE-V measures, there were statistically significant improvements in overall severity, breathiness, and loudness 1 month after injection.

"The only thing that got worse is called roughness, but that would be expected because of the better volume," Klepitskaya said. Twenty-four of the 27 subjects (89%) reported a positive effect of treatment 1 month after injection.

Table 1. CAPE-V Scores (Mean ± SD)

End Point Screening Visit Baseline 1-Month Post Injection P Value: 1-Month vs Screening P Value: 1-Month vs Baseline
Overall Severity 57.6 ± 20.6 58.5 ± 20.3 45.0 ± 19.6 .0443 .0012
Roughness 22.3± 13.1 22.9 ± 14.6 31.3 ± 17.8 .0355 .2887
Breathiness 36.0 ± 26.9 30.4 ± 25.1 19.5 ± 24.0 .041 .0279
Strain 32.2 ± 23.7 31.3 ± 26.9 26.8 ± 17.3 .6588 .1424
Loudness 52.7 ± 22.8 53.5 ± 26.4 34.3 ± 29.7 .0048 .001

Glottic closure time increased (improved) 16.43% 1 month after injection compared with the screening visit, and it increased by 10.82% compared with baseline (< .001 for both). There was no significant difference at baseline compared with the screening visit 1 month earlier.

There were no differences pre- and postinjection for the subjective outcomes of the Voice Handicap Index-10 (VHI-10), a 10-question tool measuring patients' perception of their voice, and the Eating Assessment Tool (EAT-10) for their perception of their swallowing and eating abilities.

If the CMC gel was successful, by 3 months the effect would wear off. Then the otolaryngologist would inject a calcium hydroxyapatite paste, which Klepitskaya said should last up to 18 months, so she is following the patients to see when that effect will wear off.

She said she "absolutely" advocates using the short-acting gel first to see if the voice improves, and then going to the long-acting one if warranted. In this trial, a large majority of the patients benefited from the initial short-acting gel injection.

Joseph Quinn, MD, Oregon Health and Science University, Portland, said he was impressed with the data. "I think it could really make a difference for our patients," he said. "I like the fact that there's an objective appearance that makes the diagnosis and then a short-term trial period. I think all those are really attractive."

He noted that sometimes physicians do not appreciate some of the changes that patients have that are not specific to PD, such as those that just accompany normal aging, such as voice changes. Those, too, can affect functioning and quality of life, he said.

The study was partially funded by the Davis Phinney Foundation. Klepitskaya had no relevant disclosures. Quinn reported receiving search support from abbvie and Sanofi.

International Congress of Parkinson’s Disease and Movement Disorders (MDS) 2018: Abstract 220. Presented October 6, 2018.

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