Biomedical subjects

Albert L Merati

Publications and source records attributed to Albert L Merati.

At least 19 recordsLinked to original sources

PubMed2006

Acute and subacute awake injection laryngoplasty for thoracic surgery patients.

SUMMARY: The rehabilitation of glottic incompetence by injection laryngoplasty is important in the management of thoracic surgery patients with vocal cord paralysis. This group of patients presents special considerations that favor injection under local anesthesia. The objective of this study is to characterize our experience with this minimally invasive approach in both the acute and subacute settings. The study was conducted using a retrospective chart review. From a database of 108 patients who received awake percutaneous injection laryngoplasty over a 3-year period, 15 cases were identified that underwent augmentation shortly following thoracic surgery. These records were reviewed for patient demographics, clinical characteristics, complications, and short-term outcomes. Fifteen patients were identified (12 male, 3 female); the age range for the group was 18-91 years (median=55 years). All the patients reported vocal improvement following injection; all 15 also were improved by perceptual assessment. Five of six dysphagic patients improved following injection. One patient's injection was aborted due to vocal fold edema; no significant bleeding or airway embarrassment was observed. No procedures were terminated because of patient discomfort. Awake percutaneous injection laryngoplasty for vocal paralysis can be performed safely in the postoperative thoracic surgery patient. Swallowing and voice complaints were almost universally improved following treatment. For patients who cannot tolerate or choose not to have open thyroplasty or vocal fold injection under general anesthesia, this procedure may offer a safe and effective alternative.

Acute Disease↗

PubMed2006

Mitomycin-c application in airway stenosis surgery: analysis of safety and costs.

OBJECTIVE: This study describes a large series of patients receiving topical mitomycin-c (MMC) during airway surgery, including complications, and carries out a cost analysis for its use in laryngotracheal stenosis. STUDY DESIGN AND SETTING: Retrospective review, tertiary center. Airway patients receiving MMC are reviewed for demographics, stenosis characteristics, and MMC usage. A basic cost analysis is carried out. RESULTS: Fifty patients underwent 93 MMC applications (mean = 50.8 years, 25 male, 25 female). In 89 of 93 applications (96%), the concentration of MMC was 0.4 mg/ml. One major complication occurred (1.1%). The expense for MMC is $455; the mean cost for airway surgery is $7,840. It is estimated that if 1 of 17 MMC treated patients requires one less operation, the cost ratio is favorable. CONCLUSIONS: This large series contributes to literature that MMC is a safe adjunct to laryngotracheal surgery. The marginal cost for MMC application is favorable based on our basic cost analysis and existing efficacy data. SIGNIFICANCE: Mitomycin-c seems to be safe and cost-effective in endoscopic airway surgery. EBM RATING: C-4.

Anesthesia, General↗

PubMed2006

Association of airway abnormalities and risk factors in 37 subglottic stenosis patients.

OBJECTIVES: The study objective is to characterize the airway abnormalities in a series of patients with subglottic stenosis (SGS) as they relate to etiology and risk factors. STUDY DESIGN AND SETTING: Retrospective review, academic medical center. Airway characteristics, patient demographics, and suspected risk factors were recorded from a database of SGS cases from 2001 to 2004. RESULTS: Thirty-seven patients with SGS were identified; 22 of 37 had isolated SGS (59%). Intubation (10 of 37, 27%), high tracheotomy (4 of 37, 11%), and reflux (5 of 37, 14%) comprised the bulk of cases; 13 of 37 (35%) were considered idiopathic. Of 22 patients with isolated SGS, the majority 18 of 22 (P = 0.06) were women, 59% of which were idiopathic. Multiple-level cases (0 of 15) were idiopathic (P < 0.001). Intubation was the most common cause of multiple site stenosis (6 of 15, 40%). CONCLUSIONS: The majority of patients in this study had isolated lesions. These patients tend to have no apparent risk factors. Multi-level cases are associated with prolonged intubation and known injuries. The nature of "idiopathic" stenoses is discussed. SIGNIFICANCE: Clinical examination of SGS may be meaningful in understanding the etiology of the stenosis.

Cohort Studies↗

PubMed2006

Management of vocal paralysis: a comparison of adult and pediatric practices.

OBJECTIVE: To compare practices of the American Broncho-Esophagological Association (ABEA) membership regarding the evaluation and management of unilateral vocal fold motion impairment (UVFMI) in adult versus pediatric populations. STUDY DESIGN AND SETTING: An 18-item adult survey and 16-item pediatric survey were administered to ABEA members. RESULTS: Seventy-six adult (31%) and 35 pediatric surveys (43%) were completed. Key differences are highlighted. With respect to etiology, the most common reported childhood cause is idiopathic; adults more often suffer iatrogenic paralysis. Children more commonly experience reflux disease, feeding difficulties, and choking. Preferred testing involves flexible laryngoscopy and chest x-ray; however, laboratory tests are carried out less often in children (51% vs 71%) and medical intervention is advocated by fewer pediatric practitioners (39% vs 57%). CONCLUSION: Significant disparities exist in the etiology, presenting symptoms, diagnostic testing, and medical treatment between children and adults with UVFMI. SIGNIFICANCE: Clinicians' perceptions regarding UVFMI may reflect the differing impact of vocal paralysis in the pediatric versus adult populations.

Adult↗

PubMed2006

Perceptual voice analysis of patients with subglottic stenosis.

OBJECTIVES: To characterize the perceptual assessment of vocal quality in subglottic stenosis (SGS) patients and to identify risk factors for dysphonia. STUDY DESIGN AND SETTING: Retrospective review, academic center. METHODS: Perceptual voice assessment using GRBAS scale (Grade, Roughness, Breathiness, Asthenia, Strain); patient characteristics determined for 31 SGS cases. RESULTS: The mean GRBAS (0 to 3 scale, 0 = normal quality) for SGS patients at their initial visit was G(1.4)R(1.2)B(0.5)A(0.5)S(1.1). For males vs females: G(2.1 vs 1.1)R(2.0 vs 0.8)B(1.0 vs 0.4)A(1.0 vs 0.3)S(1.7 vs 0.9). The Grade (P < 0.03), Breathiness (P < 0.04), and Asthenia (P < 0.02) assessments were significantly more dysphonic in patients with multilevel stenosis; vocal fold motion impairment (VFMI) also impacted overall Grade (P < 0.01). Overall Grade (P < 0.002), Roughness (P < 0.007), and Breathiness (P < 0.006) were significantly worse in patients with prior airway surgery. CONCLUSION: SGS patients demonstrate a mild to moderate change in perceptual voice characteristics with males in this series being more affected than females. Negative risk factors include multiple stenoses, VFMI, and previous airway surgery. SIGNIFICANCE: This is the first systematic report of perceptual voice assessment in subglottic stenosis. SGS patients have notable degrees of dysphonia with identifiable risk factors.

Auditory Perception↗

PubMed2006

Diagnostic testing for vocal fold paralysis: survey of practice and evidence-based medicine review.

OBJECTIVES/HYPOTHESIS: Vocal fold paralysis continues to be a dominant topic in laryngology. Although the majority of cases can be attributed to a known etiology, a significant number of patients present without a clear precipitating event. Over 1,500 studies regarding vocal fold paralysis exist in the medical literature, although only a small percentage report on the use of serum or radiographic testing for the evaluation of idiopathic paralysis. Despite this, patients are routinely subjected to diagnostic evaluation to investigate the underlying cause. To characterize contemporary practice, a national survey of the American Broncho-Esophagological Association (ABEA) membership was undertaken. It is hypothesized that the current practice of diagnostic testing for idiopathic vocal fold paralysis is not well supported by an evidence-based medicine (EBM) review of the available medical literature. STUDY DESIGN: The authors conducted a national survey, systematic EBM review of existing literature. METHODS: Surveys were mailed to all active ABEA members; responses regarding practice specialization as well as serum/radiographic diagnostic preferences for idiopathic vocal fold paralysis were tabulated and subjected to statistical analysis. To compare contemporary practice with evidence in the available literature, an EBM review was first performed. Articles for evaluation were selected from a Medline search of English-language abstracts related to adult vocal fold paralysis. The publications were individually reviewed and an EBM level and grade were assigned and compared with the survey results. RESULTS: Eighty-four of 249 active members responded with 76 (31%) replies submitted for analysis. Specific serum tests were advocated by 41 of 76 (54%) respondents, although the majority (52 of 65 [80%]) felt that they were only "occasionally" or "never" necessary. The most common tests were rheumatoid factor (38%), Lyme titer (36%), erythrocyte sedimentation rate (34%), and antinuclear antibody (33%). Fifty-one of 71(72%) felt that computed tomography (CT) was "always" or "often" necessary and 50 of 72 (69%) replied that chest radiography (CXR) was "always" or "often" necessary. There was no significant difference between CT and CXR ordering (P < .51). In contrast, magnetic resonance imaging (MRI) was described as "always" or "often" necessary in 28 of 71 (39%) of the surveys, significantly less than CT (P < .0001). There was no statistical impact of practice specialization on ordering of serum tests (P = .25) or imaging (P = .50 for CT; P = .46 for CXR; P = .45 for MRI). Following analysis of 1,510 vocal fold paralysis abstracts, 19 publications were found to be appropriate for an EBM review of serum testing with 15 available for review of radiographic imaging. Only one study presented level III evidence; the remainder were levels IV and V comprised of retrospective series and case reports. The evidence supporting serum or radiographic testing toward the evaluation of idiopathic vocal fold paralysis is given an overall grade of "C." CONCLUSIONS: Serum and radiographic testing for the evaluation of vocal fold paralysis is supported by grade "C" evidence only. There are no existing prospective studies estimating the clinical impact of testing on diagnosis or patient outcome. Current practice, as estimated by a survey of the ABEA membership, is not well founded for serum testing and only by retrospective case series with regard to imaging. Further study into the nature of idiopathic vocal fold paralysis and outcomes assessment of diagnostic paradigms may improve clinical practice.

Adult↗

PubMed2006

Electromyography findings of the cricopharyngeus in association with ipsilateral pharyngeal and laryngeal muscles.

OBJECTIVES: We reviewed a large series of cricopharyngeal (CP) muscle electromyography (EMG) results and compared them with the EMG results from the inferior constrictor (IC), thyroarytenoid, (TA), cricothyroid (CT), and posterior cricoarytenoid (PCA) muscles. METHODS: We performed a retrospective review of all CP muscle EMG reports from studies performed between January 1996 and June 2003. All of the tested elements from the CP muscle EMG reports were recorded. The EMG results were recorded for the ipsilateral IC, TA, CT, and PCA muscles if they were simultaneously tested. Each muscle result was classified as normal, neurogenic inactive axonal injury (IAI), or neurogenic active axonal injury (AAI), and the muscle findings were compared. A patient chart review was performed to determine a clinical correlation. RESULTS: Fifty-nine patients underwent CP muscle EMG. Eighteen patients had bilateral EMG studies, making a total of 77 CP muscle studies. Nineteen sets of CP muscle results were normal, 43 demonstrated neurogenic IAI, and 15 demonstrated neurogenic AAI. The ipsilateral IC and CP muscles had the same innervation status in 27 of 28 studies (p < .0001). When the ipsilateral TA muscle was studied simultaneously with the CP muscle, 31 of 50 studies had the same innervation status (p = .005). The ipsilateral CT and CP muscles demonstrated the same innervation status in 40 of 50 studies (p < .0001). The correlations between the CP and IC muscle findings and between the CP and CT muscle findings were both stronger than the correlation between the CP and TA muscle findings (p < .0001 and p = .024, respectively). The chart review demonstrated the clinical findings to be consistent with the EMG results. CONCLUSIONS: The EMG studies demonstrated that CP muscle findings have the strongest correlation with IC muscle findings, followed by the CT and TA muscles. This outcome does not support theories indicating that the recurrent laryngeal nerve innervates the CP muscle in all cases.

Electromyography↗

PubMed2005

Common movement disorders affecting the larynx: a report from the neurolaryngology committee of the AAO-HNS.

Laryngeal physiology depends on dynamic neuromuscular forces acting on a basic framework of cartilage and specialized soft tissues, that is, the vocal folds. A working understanding of this organ in health and disease requires knowledge of specific neurological processes that may affect voice, swallowing, and airway regulation. Neuromuscular impairment continues to be a dominant topic in the study of laryngeal disorders. This subcommittee presentation reviews important aspects of the neurolaryngeal history and physical examination. After this foundation, 4 common movement disorders affecting the larynx are covered in separate subsections. These are stroke, Parkinson's disease, laryngeal tremor, and spasmodic dysphonia. State-of-the-art reviews reflecting our understanding of these clinical issues are presented in this summary.

Age Distribution↗

PubMed2005

Does successful segmental tracheal resection require releasing maneuvers?

OBJECTIVES: Tracheal resection is a well-established option for the management of airway stenosis. Releasing maneuvers have been described to reduce anastomotic tension. The aim of this study is to report on a series of tracheal resections performed without the use of these maneuvers. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary hospital. METHODS: All patients undergoing tracheal resection by the first author over a 6-year period were reviewed. RESULTS: Patients (n = 17; 7 men and 10 women, ages 23-76) were managed with tracheal resection and anastomosis without stenting or postoperative tracheotomy. 16/17 (94%) patients had successful treatment of their stenosis. 1/17 (6%) failed and 1/17 (6%) required dilation. There was no postoperative swallowing dysfunction. CONCLUSIONS: Segmental tracheal resection without releasing maneuvers was successful in 16/17 (94%) patients. SIGNIFICANCE: Though extrapolation from this series may be limited, future practitioners may consider forgoing additional releasing maneuvers for tracheal resection in many cases.

Adult↗

PubMed2005

Medialization thyroplasty window creation using an ultrasonic surgical aspirator.

OBJECTIVES/HYPOTHESIS: The aim of the study was to investigate the use of an ultrasonic surgical aspirator for creation of the laryngeal cartilage window during medialization thyroplasty. STUDY DESIGN: Basic science. METHODS: Forty thyroplasty windows were constructed in fresh, unpreserved cadaver larynges. A 6 x 13-mm rectangular window and a 4 x 4-mm round window were created on each side of the larynges in a symmetrical fashion. A standard surgical drill with a 3-mm cutting burr was used on one side; the ultrasonic surgical aspirator was used on the contralateral side. The time required for window construction was recorded, as was the status of the inner perichondrium at window completion. RESULTS: For creation of the 6 x 13-mm window, a mean time of 128 seconds was required using a standard surgical drill. The mean time using the ultrasonic aspirator device was 91 seconds for the window of the same size (P < .008). For the 4-mm round window, drilling completed the task in a mean time of 63 seconds, compared with 40 seconds (P < .016) for the ultrasonic aspirator. On creation of the 6 x 13-mm window, there were 4 of 10 perichondrial violations in the drilled specimens, and there were no violations in creation of the window of the same size with the ultrasonic aspirator (P = .12). The 4-mm round window had no perichondrium violations in the standard drill group and only 1 of 10 violations in the ultrasonic aspirator group (P = .99). CONCLUSION: The study suggested that the ultrasonic surgical aspirator device may be an effective, efficient alternative to the standard drill for medialization thyroplasty window creation. Prospective clinical trials are warranted to better characterize its applicability.

Female↗

PubMed2005

Meta-analysis of upper probe measurements in normal subjects and patients with laryngopharyngeal reflux.

We report a meta-analysis of a series of studies in which 24-hour ambulatory pH monitoring was performed in 1) normal subjects, 2) the normal control subjects in studies of laryngopharyngeal reflux (LPR), and 3) the patients with LPR in these controlled studies. The statistical analysis utilized the fixed-effects model by Mantel-Haenszel and the random-effects mixed model. There were 16 studies from the past 12 years that fulfilled the inclusion criteria. They involved 793 subjects (264 normal and 529 with LPR). The numbers of positive pharyngeal reflux events for normal subjects and for patients with LPR differed with a p value of <.0001. There was also a significant difference in the mean percentage of acid exposure times between normal subjects and patients with LPR (p = .003). We conclude that the upper probe gives accurate and consistent information in normal subjects and patients with LPR. The numbers of reflux events and acid exposure times are most important in distinguishing normal subjects from patients with LPR. The technology and methodology of probe testing is quite reliable and is consistent on a worldwide basis.

Case-Control Studies↗

PubMed2005

Laryngeal electromyography for adult unilateral vocal fold immobility: a survey of the American Broncho-Esophagological Association.

OBJECTIVES: Diagnostic and management strategies for adult unilateral vocal fold immobility (UVFI) vary among otolaryngologists. The aim of this study was to determine the current attitudes and practices regarding laryngeal electromyography (LEMG) for the management of adult UVFI within a cohort of subspecialty laryngologists. METHODS: A 19-item instrument focused on diagnosis and management of adult UVFI was mailed to active members (n = 249) of the American Broncho-Esophagological Association (ABEA). The subset of questions related to LEMG is reviewed in this report. Statistical analysis using a chi2 test was performed. RESULTS: The survey response rate was 34% (n = 84), with 8 surveys returned incomplete because of pediatric-limited practices. Of the respondents, 75% (n = 57) rely on LEMG for evaluation of UVFI, whereas 25% (n = 19) do not use LEMG. Of those who use LEMG, 54% place their own electrodes and 44% interpret the LEMG results themselves. Monopolar electrodes are used by 57% (n = 25), bipolar electrodes by 27% (n = 12), and hooked-wire electrodes by 17% (n = 7). Muscles evaluated by LEMG include the thyroarytenoid (100%), cricothyroid (94%), posterior cricoarytenoid (70%), lateral cricoarytenoid (43%), cricopharyngeus (27%), and interarytenoid (17%). The LEMG is performed in an unblinded fashion by most respondents (85%), and many (66%) feel a more accurate result is obtained when clinical information is known. There was no statistically significant difference in use of LEMG, placement of electrodes, and interpretation of LEMG according to percentage of laryngology practice. CONCLUSIONS: The survey results demonstrate congruence among ABEA members in the utility of LEMG in the management of adult UVFI. Some variability was noted in the methods by which LEMG is performed and interpreted.

Attitude of Health Personnel↗

PubMed2004

STAT3 activation in recurrent respiratory papillomatosis.

BACKGROUND: The activation of signal transducer and activator of transduction (STAT) protein is thought to lead to the genesis of neoplasia by promoting cellular growth and preventing apoptosis, and by immune system modulation; STAT3 protein has also been implicated in tumor survival and propagation in recurrent respiratory papillomatosis (RRP). OBJECTIVES: To investigate the presence and activation of STAT3 protein in papilloma specimens from subjects with RRP and compare findings with those obtained from control subjects' tissue. DESIGN: Laryngeal papilloma samples were collected from 8 nonselected consecutive patients undergoing surgery for RRP, and control samples of anterior tonsillar pillar mucosa were collected from 8 patients undergoing adenotonsillectomy. After extraction, we applied gel shifting to the nuclear protein using an electromotility shifting assay kit. Quantitative analysis of the gel shifts was performed, and levels of activated STAT3 protein in RRP specimens and tissue from controls were compared. RESULTS: There was STAT3 protein activation in the nuclear extracts of all (100%) RRP specimens, which was significantly more frequent than in normal epithelial tissue from controls (P<.03). CONCLUSIONS: We conclude that STAT3 protein activation is present in RRP. However, further study is needed to determine if STAT3 protein activation is an important pathway through which human papillomavirus results in the propagation and persistence of RRP.

Blotting, Western↗

PubMed2004

Concurrent laryngeal abnormalities in patients with paradoxical vocal fold dysfunction.

OBJECTIVE: Our goal was to investigate the presence of laryngeal abnormalities is patients with paradoxical vocal fold dysfunction (PVFD). STUDY DESIGN AND SETTING: A retrospective chart review was performed of patients referred for evaluation of paradoxical vocal fold dysfunction between July 2002 and December 2002. The patients completed questionnaires at the time of the office visit. Data collected from the medical record included age, gender, duration of symptoms before evaluation, asthma, gastroesophageal reflux symptoms, and laryngoscopic findings. Exercise stress test was performed when suitable. The diagnosis of PVFD was made based on patient history and laryngoscopy. RESULTS: Thirty patients were identified. There was a 27:3 (90%) female predominance, and mean age of presentation at was 28 years (range, 12 to 67 years). The median time from the onset of respiratory symptoms to diagnosis was 4.5 years (range, 0.5 to 30 years). Of the 30 patients, 17 (56%) had asthma, 16 had laryngeal findings suggestive of gastroesophageal reflex disease, 4 (12%) had laryngoscopic findings of chronic laryngitis, and 10 (33%) had additional findings, including laryngomalacia, vocal fold motion impairment, sulcus vocalis, nodules, and subglottic stenosis, mostly in the exercise-induced group. CONCLUSIONS: Concomitant laryngeal abnormalities are present in a many patients with PVFD, particularly in those with exercise-induced symptoms. Laryngoscopy is important in the management of these patients.

Adolescent↗

PubMed2004

The utility of routine chest radiography following jet ventilation in elective laryngotracheal surgery.

OBJECTIVES/HYPOTHESIS: Jet ventilation is a useful mode of airway management for laryngotracheal surgery. The objective of this study is to evaluate the utility of routine chest radiography following jet ventilation for these cases. STUDY DESIGN: Retrospective chart review. METHODS: Thirty-four elective surgical procedures performed from 1998 to 2002 are reviewed for postoperative airway and pulmonary complications. Data were collected from clinical notes as well as from the results of chest radiographs. This included the need for tracheotomy, reintubation, pneumothorax, pneumomediastinum, and atelectasis. RESULTS: A retrospective chart examination revealed no major complications. Twenty-nine of the 34 cases had postoperative chest radiography (CXR) performed on a routine basis. Atelectasis was present in 12 of 29 CXR (41%); no intervention was required in these cases. CONCLUSIONS: Routine postoperative CXR may not be useful following jet ventilation for elective laryngotracheal surgery. The safety of jet ventilation is discussed.

Adult↗

PubMed2004

Voice changes after androgen therapy for hypogonadotrophic hypogonadism.

OBJECTIVES/HYPOTHESIS: Males with isolated hypogonadotropic hypogonadism (IHH) fail to undergo normal sexual development, including the lack of masculinization of the larynx. The objective of this study was to measure the mean vocal fundamental frequency (MF0) in IHH patients and determine the impact of androgen treatment. An additional aim was to compare the MF0 between IHH patients and controls. STUDY DESIGN: Prospective observational study. METHODS: Twenty-four patients with IHH were identified along with 30 normal males and females. Voice recordings were obtained on all subjects. Androgen therapy was administered to the IHH patients. The MF0 and serum sex hormone levels were measured before treatment and at intervals during therapy. These results were compared with the pretreatment data within the IHH group. Voice parameters were also compared between the pre- and posttreatment IHH patients and the normal males and females. RESULTS: The MF0 in untreated IHH patients was 229 +/- 41 Hz. This was intermediate between the normal male (150 +/- 22 Hz, P < .001) and normal female patients (256 +/- 29 Hz, P < .01). After treatment, the MF0 in the IHH group decreased to 173 +/- 30 Hz (P < .0001); indeed, their posttreatment MF0 approached that of normal males (P < .08). Serum hormone levels responded to the injected testosterone, but these levels did not directly correlate with MF0. CONCLUSIONS: MF0 in IHH patients is intermediate between normal male and female levels. After treatment with testosterone, these values approach the range of normal males. This prospective study details the impact of androgens on the larynx and vocal function in patients with IHH.

Adult↗

PubMed2003

Normal endoscopic anatomy of the pharynx and larynx.

The pharynx and larynx are readily visualized in ambulatory settings during endoscopic examination. Although these organs may be perceived as the portal to the lungs or upper digestive tract, endoscopists could refine their technical and diagnostic acumen by becoming more familiar with this special area of anatomy. Further, an anatomic description of these structures may augment the generalist's understanding of their physiologic functioning. The basic skills required for examining the pharynx and larynx are generally quite easy to obtain. This article reviews the endoscopic anatomy and basic physiology of this region and offers suggestions for improving technique.

Anesthesia↗

PubMed2003

The use of injectable collagen in the management of pediatric vocal unilateral fold paralysis.

Vocal fold paralysis (VFP) is the second most common congenital abnormality that affects the larynx. Unilateral cases may be asymptomatic or feature symptoms related to laryngeal incompetence, such as aspiration and dysphonia. Management has traditionally been conservative as a high percentage of these paralyses recover spontaneously. The literature is scant on the acute or chronic management of unilateral vocal fold paralysis related symptoms in children. We present a series of four children (age 21 days, 5 years, 5 years, and 18 years) with unilateral VFP paralysis treated with collagen (Cymmtera) augmentation for control of symptoms related to laryngeal incompetence. Two children (age 21 days and 5 years) were managed in the acute setting. Follow-up has ranged from 4 to 12 months, and all have maintained excellent outcomes. Vocal fold augmentation with collagen is an effective therapeutic option in the management of symptoms related to unilateral VFP and laryngeal incompetence. It decreases the risk of aspiration and improves vocal quality. Collagen augmentation can be used in the acute setting to decrease aspiration, possibly avoiding a tracheotomy or gastrostomy tube placement, or to augment patients with a tracheotomy who are still severely aspirating.

Adolescent↗