Augmentation laryngoplasty: Results and decision plan

Abstract

Objectives

Augmentation laryngoplasty represents a therapeutic choice for patients who suffer from glottic insufficiency of different etiologies. There have been multiple injectables that have been proven effective. The present study examines the short‐term effects of vocal fold augmentation on phonation, swallowing, and breathing in individuals with glottic insufficiency. In addition, a decision plan is also proposed.

Methods

Data from medical records and operative notes were used to conduct a retrospective cohort study on patients with glottic insufficiency who underwent vocal fold augmentation from 2016 to 2023. Hyaluronic acid, calcium hydroxyapatite, and polydimethylsiloxane were the injectable materials that were used. An analysis was conducted on phonation, breathing, swallowing, and laryngoscopy findings both before and after vocal folds' augmentation.

Results

Seventy‐nine patients were included, which represents 97 injections. The median (IQR) preoperative Voice Handicap Index‐10 (VHI‐10) score improved from 21 (15–28) to 16 (9–25) postoperatively (p < 0.001). The GRBAS scale also significantly decreased (p < 0.001). The median (IQR) preoperative Dyspnea Index score improved from 6 (0–17) to 2 (0–10) postoperatively (p < 0.05). Laryngoscopic findings showed significant improvement in the bulk of the vocal folds. There was no significant change in swallowing.

Conclusions

In case of dysphonia secondary to glottic insufficiency, augmentation laryngoplasty using various injectable materials has proven to be an effective option across a range of different etiologies, as it results in significant improvements in voice quality. The choice of the injectable material depends upon the severity and the etiology of glottic insufficiency.

Key points

• When deciding on the best injection material for augmentation laryngoplasty, the patient's age, overall health, and the cause and severity of their glottic insufficiency must be considered.

• Percutaneous vocal fold augmentation under local anesthesia shows better voice quality results compared to vocal fold augmentation under general anesthesia through suspension laryngoscopy.

INTRODUCTION

Dysphonia is the primary symptom of glottic insufficiency, which is identified by incomplete closure of the vocal folds during phonation. ¹ This pathology can be caused by multiple etiologies such as scar, atrophy, presbylarynx, and vocal fold paralysis or paresis. ² The chronic impact of glottic insufficiency on patients significantly affects their quality of life. This results in vocal alterations, such as hoarseness, weak voice, and breathy voice. ³ Patients frequently face challenges with their voice and may undergo alterations in their sense of self. Airway protection during swallowing is a crucial role played by the vocal folds, and dysphagia can result from glottic insufficiency. ⁴

The current medical knowledge state allows for the possibility of providing these patients with an augmentation laryngoplasty. ⁵ Developed by Bruening in 1911, injection augmentation has remained a standard treatment over time. ⁶ The substance initially utilized was paraffin; however, presently, a wide selection of synthetic and biologic materials are available to serve as alternatives for vocal fold augmentation. The characteristics of injectable substances vary, with some substances being resorbable and exhibiting either short‐term or long‐term effects, while others are non‐resorbable and have a permanent effect. ⁷ , ⁸

The selection of injectables will depend on the etiology of glottic insufficiency and the expected outcome. To exemplify, temporary injectables, particularly those with a short‐term effect, are utilized in the first 9 months of glottic insufficiency arising from vocal fold paralysis, as this period represents the duration required for spontaneous recovery from such paralysis. ⁸ Moreover, injection of a resorbable substance facilitates correction of glottic insufficiency and allows for the evaluation of voice correction and patient tolerance, before the injection of a long‐term or non‐resorbable product. Hence, most patients require repeated injections before a potentially definitive solution being considered.

Multiple studies have been conducted on augmentation laryngoplasty; however, each study isolates a specific injectable and well‐defined etiology. The main objective of this study is to investigate the effects of various injectables used in vocal fold augmentation on the phonation, swallowing, and breathing abilities of patients with glottic insufficiency resulting from multiple etiologies. Moreover, we suggest a decision plan for the management of these patients.

MATERIALS AND METHODS

Study design

A retrospective review was conducted on a series of consecutive patients with dysphonia caused by glottic insufficiency. These patients underwent augmentation laryngoplasty between January 2016 and February 2023. The exclusion criteria included patients under the age of 18 and those who had died before the postoperative follow‐up. All procedures performed in the study were in accordance with the ethical standards of the institution and with the 1964 Helsinki declaration and its later amendments. In addition, our study got the approval of the National Committee of Data Privacy to use health record data of patients included in the study.

The preoperative and postoperative follow‐up visits involved the evaluation of different objective and subjective criteria related to laryngeal functions.

Patient's evaluation

All patients underwent flexible or rigid laryngoscopy with stroboscopy under local anesthesia with a color video flexible or rigid endoscope (Xion EndoSTROBE®) to evaluate the larynx during phonation and breathing before and after augmentation laryngoplasty. The data that were analyzed included the bulk, the position of the vocal folds during phonation and at rest, and the amplitude of vibration during phonation, which refers to the lateral movement extent of each vocal fold during phonation at the same frequency before and after augmentation. The amplitude of vibration involved measuring the medial edge displacement of the vocal fold from its position at the closed phase of the vibratory cycle to its position at the maximal open point of the cycle. Moreover, we looked for signs of muscle tension patterns, including glottic and supraglottic constriction in the anteroposterior and/or lateral dimensions. ⁹ We also looked for any associated vocal fold tremors.

All patients filled out a Dyspnea Index, ¹⁰ (Voice Handicap Index‐10 (VHI‐10), ¹¹ , ¹² , ¹³ (Voice‐Related Quality Of Life (VRQOL), ¹⁴ , ¹⁵ and (Eating Assessment Tool (EAT‐10) ¹⁶ questionnaires preoperatively on the postoperative visit. We analyzed the acoustic parameters of fundamental frequency (F0 in Hz), the Jitter, the Shimmer, the maximum phonation time (MPT), and the harmonics‐to‐noise ratio (HNR, dB) of a sustained vowel [i]. Objective voice evaluation was done by a speech pathologist and was based on the GRBAS scale (Grade, Roughness, Breathiness, Asthenia, Strain). ¹⁷ The speech pathologist was blinded to the preoperative and postoperative paired voice samples.

Surgical technique

All procedures were performed under general or local anesthesia by the senior author.

Augmentation laryngoplasty under general anesthesia is performed through suspension laryngoscopy (using the Lindholm laryngoscope made by KARL STORZ, Germany). The patient can be either kept under spontaneous ventilation, optimally ventilated by low‐frequency jet ventilation, or intubated. The vocal folds are examined by a HOPKINS® Forward‐Oblique Telescope 30° (KARL STORZ). The injection is performed in thyroarytenoid muscle using a 25‐cm‐long needle with a 24‐gauge malleable tip (RENÚ®Cytophil, Inc.). The injected material is contoured gently using a Bouchayer microforceps (Micro‐France) and an adrenaline‐soaked pledget, following a distal‐proximal and anterior‐posterior approach, thus producing a smooth convexity.

Augmentation laryngoplasty is performed via the cricothyroid approach under local anesthesia, aided by transnasal flexible laryngoscopy control. The cricoid and thyroid cartilages are first palpated. Next, the index finger of the non‐injecting hand is placed over the cricothyroid membrane at the level of the inferior thyroid ala. A 3.5‐inch‐long 22‐gauge needle (Spinoscan, B. Braun) pre‐bent at an angle of approximately 30° about 2 cm from its end is inserted in the midline perpendicularly making contact with the lower border of the thyroid cartilage. Once the needle tip is discernible submucosally, it is directed toward the paraglottic space, with a superior and lateral trajectory. While watching on the video monitor, the needle is manipulated gently while injecting a small amount of the augmenting material to help identify the intralaryngeal position of the tip. Next, the material is injected while visualizating for adequate medialization of the vocal fold.

Injected materials

Different injectable materials have been used. Hyaluronic acid (Restylane®) and calcium hydroxyapatite (RENÚ® Voice Cytophil, Inc. or Radiesse®) were injected under local and general anesthesia. ³ , ¹⁸ In a few selected cases, we also injected polydimethylsiloxane (VOX implant®, Cogentix Medical) through suspension laryngoscopy under general anesthesia. ¹⁹ , ²⁰ , ²¹

Statistical analysis

Statistical analyses were conducted on R (version 4.3.1 [2023‐06] Copyright © 2023, The R foundation for Statistical Computing). Descriptive statistics were expressed in median value and interquartile range or mean and range. Preoperative versus postoperative scores were compared using a paired Wilcoxon signed‐rank test for each measure (VHI‐10, VRQOL, EAT‐10, DI, GRBAS, Jitter, Shimmer, Pitch, HNR, MPT). T‐test was used to calculate the improvement of the VHI‐10. Wilcoxon rank sum‐test was used to compare the groups for continuous variables (age, duration of surgery, operating room occupancy time, delay postoperative consultation‐surgery, quantity of product injected). Chi²‐test or Fisher test was used to compare the groups for qualitative variables. A Fisher test was also used to compare normalization of VHI‐10 postoperatively. For all tests performed, a p < 0.05 was considered statistically significant.

RESULTS

Patient's characteristics

In total, 79 cases were included which represents 97 vocal fold's augmentation (Table 1). The mean age is 63.6 years with a range of 18–88 years. The etiology of the glottic insufficiency included scar (n = 13), idiopathic vocal fold paralysis (n = 8), post‐surgery vocal fold paralysis (n = 24), presbylarynx (n = 26), and atrophy of the thyroarytenoid muscles other than presbylarynx (n = 8). Two cases were associated with laryngeal tremors.

Table 1.

Patient's characteristics.

	n (patients)	%
Gender
Male	39	49.37
Female	40	50.63
Age (years): mean (range)	63.6 (18–88)
Smoking
Yes	2	2.53
No	77	97.47
Etiology
Scar	13	16.45
Idiopathic vocal fold paralysis	8	10.13
Post‐surgery vocal fold paralysis	24	30.38
Presbylarynx	26	32.91
Thyroarytenoid muscle atrophy (other than presbylarynx)	8	10.13
	n (injections)
Injectable product
Hyaluronic acid	24	24.74
Calcium hydroxyapatite	70	72.17
Polydimethysiloxane	3	3.09
Injection
Unilateral	49	50.52
Bilateral	48	49.48
Time between injection and onset of dysphonia
>24 months	74	76.29
12–24 months	8	8.25
<12 months	15	15.46
Anesthesia
Local	17	17.53
General	80	82.47

Hyaluronic acid was used for 24 injections (24.74%), calcium hydroxyapatite for 70 (72.17%), and polydimethysiloxane for three (3.09%).

The majority of augmentation laryngoplasty procedures (83%) have been carried out under general anesthesia. Forty‐nine patients underwent unilateral injections while 48 underwent bilateral injections.

More than three‐fourths (76%) of the injections were performed after 24 months from the onset of dysphonia, while only 15 injections were administered during the first year of the voice disorder.

The average length of the surgical procedure was 17.4 min, with a range of 4–45 min.

On average, the postoperative visit was conducted 30–60 days after the injection laryngoplasty. The average follow‐up period was 1 year.

Phonation

The median (IQR) preoperative VHI‐10 score improved from 21 (15–28) to 16 (9–25) postoperatively (p < 0.001). The percentage improvement of the VHI‐10 is 17.84% with a VHI‐10 of 4.6 (p < 0.001).

We also performed a Fisher test to calculate the number of patients with normalization of VHI‐10 score postoperatively. Preoperatively, we only had 7 patients who presented a non‐pathological VHI‐10 score (score £ 11), while postoperatively we identified 20 patients. This difference is statistically significant (p < 0.05) with an odds ratio of 0.28 and a 95% CI [0.093; 0.759] (Table 2).

Table 2.

Self‐assessment questionnaire and GRBAS scale analysis.

parameters	Preoperative Median [q1‐q3]	Postoperative median [q1‐q3]	p Valuea
vhi‐10	21 [15–28]	16 [9–25]	<0.001
vrqol	28 [21–36]	24 [15–31]	<0.001
eat‐10	3 [0–11]	1 [0–8]	0.11
di	6 [0–17]	2 [0–10]	<0.05
g	2 [1–2]	1 [1–2]	<0.001
r	1 [1‐2]	1 [0–1.75]	<0.001
b	1 [0.5–3]	0 [0–‐1]	<0.001
a	1 [0–1]	0.5 [0–1]	<0.001
s	1 [0–1]	0 [0–1]	<0.001

^a Paired Wilcoxon signed‐rank test.

The median (IQR) preoperative VRQOL score improved from 28 (21–36) to 24 (15–31) after surgery (p < 0.001). The GRBAS scale is also statistically significantly improved postoperatively (p < 0.001) (Table 2).

The median (IQR) MPT is not significantly different between different follow‐up visits: from 2.88s (1.33–5.3) to 3.18s (2.37–5.4) (p = 0.08).

Analysis of acoustic parameters for high‐pitched [i] showed only jitter to have significant improvement. The median decreases from 1.20% to 0.98% after surgery (p < 0.05).

For the other acoustic parameters, shimmer, pitch and HNR, there were no differences between the pre‐ and postoperative follow‐up visits (p = 0.07; p = 0.41; p = 0.31) (Table 3).

Table 3.

Acoustic parameters analysis for [i].

	[I] high‐pitched median [Q1–Q3]
parameters	Preoperative	Postoperative	p Valuea
Jitter (%)	1.20 [0.97–2.11]	0.98 [0.85–1.24]	<0.05
Shimmer (%)	7.32 [4.59–10.06]	5.63 [4.20–8.38]	0.07
Pitch (hz)	288.9 [224.6–345.5]	306.8 [230.3–381.2]	0.41
hnr (db)	17.84 [13.09–22.34]	18.49 [16.04–21.67]	0.31

parameters	[i] low‐pitched median [Q1–q3]		p Value a
	Preoperative	Postoperative
jitter (%)	1.25 [0.97–1.79]	0.98 [0.80–1.60]	0.06
Shimmer (%)	7.74 [6.03–11.90]	6.90 [4.86–10.17]	0.12
Pitch (hz)	198.70 [162.54–228.44]	218,6 [165.1–265]	<0.05
hnr (db)	17.82 [13.55–20.07]	17.57 [14.54–20.37]	0.59

^a Paired Wilcoxon signed‐rank test.

We found a statistically significant difference (p < 0.05) between the preoperative and postoperative median pitch (198.7 Hz vs. 218.6 Hz) for [i] low‐pitched in acoustic parameters analysis. [AI1] [UMO2] For the other acoustic parameters for [i] low‐pitched, Jitter, Shimmer and HNR, there were no differences between the preoperative and postoperative follow‐up visits (p = 0.06; p = 0.12; p = 0.59) (Table 3).

Swallowing

The preoperative and postoperative EAT‐10 scores were not significantly different (p = 0.11) (Table 2).

Breathing

The median (IQR) preoperative DI score improved from 6 (0–17) to 2 (0–10) postoperatively (p < 0.05) (Table 2).

Videolaryngostroboscopy

A decrease from 16 to 4 was observed postoperatively in the number of patients showing a posterior glottic gap during laryngeal examination during phonation (p < 0.05, odds ratio 0.21, 95% CI [0.05; 0.70]).

There has been a notable improvement in the number of patients with supraglottic constriction, decreasing from 24 to 9 (p < 0.05, odds ratio 3.36, 95% CI [1.36; 8.95]). In two cases with presbylarynx, a significant decrease in the amplitude of laryngeal tremors was observed on the postoperative visit examination.

An increase in the bulk of the injected vocal fold was observed in 49 patients during the postoperative examination. This clear improvement was statistically significant (p < 0.001, odds ratio 0.10, 95% CI [0.04; 0.24]).

Regarding the other studied characteristics, such as glottic constriction and phonation vibration amplitude, no statistically significant differences were found (p = 0.21, odds ratio 0.35, 95% CI [0.06; 1.54]; p = 1, odds ratio 0.89, 95% CI [0.30; 2.60]; p = 0.28, odds ratio 0.28, 95% CI [0.54; 32.91]).

Hyaluronic acid versus calcium hydroxyapatite versus polydimethylsiloxane

The study did not yield any statistically significant differences in the improvement of VHI‐10 or acoustic parameters, either in absolute value or percentage, based on the material injected and postoperative time delay based on multivariate model (p = 0.65, p = 0.36) (Figures 1 and 2).

Figure 1.

Voice Handicap Index‐10 (VHI‐10) score improvement percentage.

Figure 2.

Voice Handicap Index‐10 (VHI‐10) score improvement in absolute value.

Complication

No complications related to surgery were observed during the follow‐up.

Local anesthesia versus general anesthesia

The VHI‐10's absolute value improvement was better under local anesthesia than general anesthesia (12 vs. 2). This difference was statistically significant (p < 0.05) (Table 4).

Table 4.

Comparison between percutaneous injection laryngoplasty under local anesthesia and injection laryngoplasty under general anesthesia.

	GA, n = 80 a	LA, n = 17a	p Valueb
quantity of product injected, mL	0, 40 (0, 30, 0, 50)	0, 45 (0, 30, 0, 95)
injection
– Unilateral	36 (45%)	13 (76%)
– Bilateral	44 (55%)	4 (24%)
duration of the procedure (min)	16 (10, 21)	20 (15, 28)	0.10
vhi‐10's improvement (%)	12 (−21, 36)	51 (20, 92)	0.073
vhi‐10's improvement (absolute value)	2 (−3, 8)	12 (6, 20)	0.037

Abbreviations: GA, general anesthesia; LA, local anesthesia.

^a Median (IQR); n (%).

^b Wilcoxon rank sum test, Fisher's exact test, Pearson's Chi‐squared test.

Decision plan

By conducting an in‐depth analysis of the different etiologies of the glottic insufficiency, examining the materials injected in each specific case, evaluating the results of the injections, and observing the therapeutic course of patients, we were able to successfully design a comprehensive decision tree that can be used to effectively manage the glottic insufficiency according to its underlying etiology (Figure 3).

Figure 3.

The decision plan for injection laryngoplasty. CH, calcium hydroxyapatite; GA, general anesthesia; HA, hyaluronic acid; LA, local anesthesia; Vox Implant, polydimethylsiloxane.

DISCUSSION

The available treatment options for glottic insufficiency consist of voice therapy, injection medialization laryngoplasty, and type I thyroplasty. Furthermore, the treatment of glottic gap caused by vocal fold paralysis may involve arytenoid adduction and laryngeal reinnervation. The augmentation of vocal folds could be a challenging task for laryngologists as they must achieve a balance between enhancing voice quality and preventing the onset of dyspnea. In this study, the treatment of glottic insufficiency was conducted through the injection of filler materials such as hyaluronic acid, calcium hydroxyapatite, or polydimethylsiloxane. The selection of the material is based on the etiology of glottic insufficiency, the duration of the pathology's evolution, and the patient's tolerance for local anesthesia. Postoperative assessment showed a decrease in the patients' perception of voice handicap, considering all material together. A significant improvement in the GRBAS scale and dyspnea index have also been demonstrated. In addition to the aforementioned findings, we also observed an improvement in some of the laryngeal examination results including a reduction in the posterior glottic gap and a decrease in supraglottic constriction. In two cases with presbylarynx, there was also a decrease of laryngeal tremors. It is possible to explain that by improving glottic insufficiency, the activation of laryngeal muscles during phonation is reduced, which subsequently reduces the severity of essential voice tremors in cases of vocal folds atrophy. ²²

The study found that there was no significant difference in the objective acoustic voice parameters after laryngoplasty using either calcium hydroxyapatite or hyaluronic acid, despite hyaluronic acid being expected to have better viscoelastic properties for phonation. ²³ , ²⁴ The long‐term impact of augmentation laryngoplasty using different materials was not a subject of study within our cohort. In several other studies, the effectiveness of calcium hydroxyapatite and hyaluronic acid as injectable materials in treating glottic insufficiency was found to be comparable over a period of 24 months, with no significant differences observed between the two in terms of their efficacy or the need for reaugmentations. ²⁵ , ²⁶ Conversely, according to certain authors, calcium hydroxylapatite has an average span of 18 months and can persist for up to 2 years, in contrast to hyaluronic acid which normally endures for 3–9 months and causes a subjective reduction in phonation after an average of 4.7 months, although some voice enhancement may be observed for up to 12 months. ² , ³ , ²⁵ The management of our patients and the creation of the decision plan were guided by the last hypothesis we followed. Other non‐resorbable substances, such as polydimethylsiloxane, can also be injected into the vocal folds. However, polydimethylsiloxane injection can be complicated by de novo or worsening of pre‐existing dysphonia or dyspnea, as well as an intense inflammatory reaction. ¹⁹ For this reason, we have reserved this material specifically for patients with irreversible vocal fold insufficiency who are in need of long‐term improvement and are unable to tolerate repeated injections or medialization laryngoplasty. These patients are typically those with glottic insufficiency in the palliative care setting. Within our series, the voice outcomes of augmentation laryngoplasty using polydimethylsiloxane were not considerably different when compared to calcium hydroxyapatite and hyaluronic acid injections. The absence of difference can be attributed to the limited number of patients who received polydimethylsiloxane injections.

It is important to acknowledge the limitations of our study due to its retrospective nature and the relatively small sample size. While our findings provide valuable insights into the effects of various injection materials on vocal fold augmentation outcomes, the limited sample size may restrict the generalizability of our results. The lack of standardized dosage for injection materials presents a potential limitation of our study, as variations in dosage may have affected the comparability of results. Given that each larynx and vocal fold size varies among individuals, determining the appropriate volume needed to achieve optimal closure of the glottic gap can be challenging. Future research should aim to develop standardized protocols for injection dosages that account for individual anatomical differences, thereby facilitating more robust comparisons between different materials.

Currently, injection augmentation laryngoplasty is frequently performed using office‐based approaches. In patients where we performed percutaneous vocal fold augmentation under local anesthesia, we found better subjective voice quality reflected by VHI‐10 score compared to vocal fold augmentation under general anesthesia through suspension laryngoscopy. This could be explained by the fact that vocal fold augmentation has a unique advantage when done under local anesthesia, as it allows the patient to be unsedated and positioned upright, which in turn facilitates monitoring the vocal fold closure pattern and voice quality during the injection. By providing customization and maximum control of the vocal fold augmentation, the procedure aims to optimize postoperative voice quality and function as continuous visualization of the dynamic larynx allows for optimal injection placement and quantity to reach an adequate functional outcome and avoid complications. ⁵ , ²⁷ It is important to emphasize that, despite thorough research, we were unable to find any studies in the literature that compare the voice outcomes of in‐office and suspension laryngoscopy vocal fold augmentation under general anesthesia.

While fewer patients received injection laryngoplasty under local anesthesia in our study, it's our current practice to offer this option to eligible patients, including the elderly and those with significant co‐morbidities. The decision is based on factors like patient preference, medical condition, and procedural feasibility. We assess patient compliance and tolerance during preoperative laryngoscopy to ensure calmness and minimal movement or swallowing, which could affect injection efficacy. Despite varying proportions, we believe local anesthesia can mitigate risks associated with general anesthesia, enhancing patient safety and experience.

The dyspnea index questionnaire was used to assess the level of dyspnea in our cohort after augmentation laryngoplasty, and we found a significant improvement. In fact, the presence of glottic insufficiency can result in upper airway‐related dyspnea, particularly when there is unilateral vocal fold flaccidity and a neurologically flail atrophic vocal fold. In addition to hypophonia, which is typically the primary complaint, laryngeal dyspnea may manifest due to passive adduction of the vocal fold, which results from the vacuum that arises at the glottis during inspiration. With increased airflow resistance secondary to the displacement of the flaccid vocal fold into the glottic aperture during forceful inspiration, the luminal diameter and airflow are diminished. The correction of glottic insufficiency by augmentation has been found to alleviate symptoms in some patients. This is because the vocal fold stiffness is increased, leading to the vocal fold no longer being drawn into the airway. ²⁸ , ²⁹ , ³⁰

The literature suggests that augmentation laryngoplasty can result in an improvement of dysphagia in patients experiencing glottic insufficiency secondary to vocal fold paralysis. ³¹ The results of our study indicate that there were no notable changes in swallowing subsequent to augmentation laryngoplasty. This finding can be accounted for by the fact that our cohort comprised patients with glottic insufficiency caused by various etiologies that could affect swallowing to varying extents. Additionally, the frequency of dysphagia may differ based on the technique utilized for detection or the criteria that are applied. The literature reports higher dysphagia prevalence estimates when patients report symptoms and lower prevalence when abnormal swallowing function is documented through instrumental assessment. This disparity might be accounted for by either the dysphagia is not severe enough to be recognized or the patients' accommodation masking the symptoms of dysphagia. ³² The assessment of swallowing in our study was limited to subjective symptoms, which were measured by the EAT‐10 score.

The lack of randomized controlled or prospective designed studies on the management of glottic insufficiency in the literature necessitates caution when interpreting the results of available techniques to treat glottic insufficiency. The treatment outcomes of most of the studies were evaluated subsequent to a decision to utilize a technique based on situational factors and the surgeon's familiarity in treating a specific type of glottic insufficiency. It is more likely that certain treatments are most effective in particular situations, as demonstrated by unreliable past experiences. For this reason, the way we approached our analysis of cases with glottic insufficiency and handled each patient has allowed us to create a decision tree for optimal management depending upon the etiology of glottic insufficiency, the chance of spontaneous recovery, and the general medical condition of the patient. To summarize, in cases where vocal fold paralysis presents a likelihood of recovery, we suggest the injection of hyaluronic acid. For cases with permanent paralysis with glottic insufficiency, we recommend medialization laryngoplasty. In case of definitive vocal fold paralysis and poor general medical condition, we advise injection of polydimethylsiloxane, if the patient is fit for general anesthesia. If not, we suggest repeated percutaneous injections of calcium hydroxyapatite. A treatment plan for vocal fold atrophy will consist of initial percutaneous injection of hyaluronic acid, followed by the option for repeated calcium hydroxyapatite injections should positive vocal outcomes be observed. Our proposal for patients with vocal fold scars is the injection of hyaluronic acid as a therapeutic trial. If the results are favorable, the injection may be repeated; otherwise, phonosurgery should be offered.

CONCLUSIONS

There are multiple injectable materials that can be used for augmentation laryngoplasty in case of glottic insufficiency with dysphonia. Voice quality can significantly improve as a result of implementing this option, which has been proven to be effective for a variety of different etiologies. When deciding on the best injection material, the patient's age, overall health, and the cause and severity of their glottic insufficiency must be taken into account.

AUTHOR CONTRIBUTIONS

We certify that all authors have seen and approved the manuscript and contributed significantly to the work.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

All procedures performed in the study were in accordance with the ethical standards of the institution and with the 1964 Helsinki Declaration and its later amendments. In addition, our study got the approval of the National Committee of Data Privacy to use health record data of patients included in the study.

Tissot L, Fabre C, Aboussouan M‐P, Castellanos PF, Atallah I. Augmentation laryngoplasty: results and decision plan. World J Otorhinolaryngol Head Neck Surg. 2025;11:232‐240. 10.1002/wjo2.212

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.