Voice disorders encompass a wide range of pathologies that result in various degrees of
voice impairment and decreased quality of life, Minimal Associated Pathological Lesions
(MAPLs), include a group of non-malignant growths on the vocal folds like vocal fold
nodules, polyps, papilloma, Reinke's oedema, polypoidal degeneration and cysts, The
pathophysiology of MAPLs include abnormal inflammatory response to local trauma.
Histologically, the superficial layer of the lamina propria shows oedema, fibrosis,
fibrin and hemosiderin deposit, interstitial haemorrhage and inflammatory cell
infiltration, Treatment options include voice therapy, intralesional steroid injections,
and surgical. Although vocal function improves and lesion regresses by vocal hygiene
advice and voice therapy, each patient receives two therapy sessions per week for about 3
months of voice treatment in the form of a holistic voice rehabilitation program. A total
of 20 sessions are conducted, with each session lasting approximately 20 minutes; Which
some patients find difficult.
Vocal folds (VFs) local steroid injection could bridge the therapeutic gap between
conservative treatment and conventional micro laryngeal surgery (MLS), Steroids are
thought to be useful for MAPLs as they share common histological features, including
oedema, thick basement membrane, inflammation, and vessel wall thickness.
Steroids act by inhibiting both collagen deposition and collagen synthesis. Also, it acts
by inhibiting fibroblastic proliferation and activity plus reduction of the extracellular
matrix deposition.
Office-based vocal fold steroid injection (VFSI) can be performed through transoral,
percutaneous and trans nasal routes, With several benefits Compared to MLS, it may be
conducted in the office under local anaesthesia in about 20 minutes, saving high costs of
general anaesthesia and hospital admission, decreasing lost workdays associated with
recurrent voice therapy sessions.
Hyaluronidase (HAase) is a preparation of proteolytic enzyme. Its injection is indicated
as an adjuvant in subcutaneous fluid administration for achieving hydration and for
improving the dispersion and the absorption of injected drugs. HAase can be used in
phono-surgery or in office applications. HAase has been useful in the following
indications: (1) HA over-injection in the vocal fold after injection laryngoplasty, (2)
treatment of Reinke's oedema and (3) in selected patients with acute vocal fold
haemorrhage, improvement of the absorption of blood products. HAase appears to be useful
in the office and the operative setting with minimal complications. There is a growing
evidence in literature that using a steroid in combination with HAase maximizes the
anti-inflammatory properties of the steroid and minimizes the side effects of steroid
therapy.
Although voice therapy may be the first line of treatment for many benign vocal folds
lesions, satisfactory outcomes are not obtained in some patients for many reasons. A
patient would attend 20 to 25 sessions of voice therapy in order to show improvement and
this would take 2 to 3 months.
Some patients, especially those from far residence, would find it difficult for them to
comply to this relatively lengthy course of therapy, resulting in a number of drop out
cases. Similarly, some professional voice users would hope to have their voice problem
alleviated in a faster way. Moreover some patients show poor understanding of the
procedure itself and hence could not implement it properly. For those reasons voice
therapy may not be appropriate for those patients.
Based on previous background, we thought that intralesional injection of a combination of
HAase and steroids into MAPls would not only provide a faster way for the patient to
restore her/his normal voice but also would augment the effect of steroids by improving
its delivery and dispersion into the lesion.
This is the first study to assess the effect of intralesional injection of a combination
of steroid and HAase in treatment of MAPLs.
The aim of this study is to assess the effect of intralesional injection of minimal
associated pathological lesions of the vocal folds by a combination of steroids and
hyaluronidase in terms of subjective and objective voice outcomes and lesion regression.