Laryngeal Reinnervation Versus Thyroplasty in Patients With Vocal Fold Weakness. (VOCALIST)

Royal National Throat, Nose and Ear Hospital

Status and phase: Completed; Phase 2

Conditions: Vocal Cord Paralysis Unilateral

Treatments: Procedure: Thyroplasty; Procedure: Reinnervation

Study type: Interventional

Funder types: Other

Identifiers

NCT02973152

11/0107

PB-PG-1013-32058 (Other Identifier)

Details and patient eligibility

About

The purpose of this study is to help determine the most effective treatment for participants with Unilateral Vocal Fold Paralysis.

There are currently two types of operations used to treat this condition. One operation is called thyroplasty. Doctors place a small piece of safe plastic into the side of the participant's voice box to push the weak vocal cord into a position to enable better speech and swallowing. In the other operation called laryngeal reinnervation, doctors repair the neck nerve supply to the vocal cord using parts of other unaffected nerves to enable better speech and swallowing. The investigators do not know which of these methods is better and are conducting this study to start comparing the two operations so that a larger clinical trial can be conducted in the future to tell us which operation is best.

Full description

Title: Does Laryngeal Reinnervation or Type I Thyroplasty give better voice results for patients with Unilateral Vocal Fold Paralysis (VOCALIST): a feasibility study

Short title: VOCALIST

Trial medication: Not Applicable

Phase of trial: Phase IIb

Objectives: The aim of the study is to establish the feasibility of a multicentre, randomised phase III clinical trial of surgical treatment for Unilateral Vocal Fold Paralysis (UVFP).

Main objectives are to test the feasibility of:

1. the multicentre recruitment process, including continuous improvement to the process based on qualitative analysis;
2. recruiters being able to present true equipoise with the treatment arms;
3. the randomisation process and investigate reasons for any difficulties that affect recruitment
4. the utility of the following characteristics of the proposed primary (voice handicap index) and secondary outcomes: variability across patients, variability over time, differences in outcome between randomised groups over time;
5. process of follow up visits and diary completion;
6. means of gathering health economics and health-related quality of life data suitable for measuring cost effectiveness.

Type of trial: Quantitative and Qualitative Feasibility Study; multi-centre randomised controlled trial

Trial design and methods: 30 patients will be randomised to receive the Laryngeal Reinnervation or Type I Thyroplasty surgery.

Trial duration per participant: 12 months

Estimated total trial duration: 24 months

Planned trial sites: Multi-site; London, Poole and Manchester (3 sites).

Total number of participants planned: 30

Statistical methodology and analysis: The trial analysis will be descriptive and will be performed on an intention to treat basis. Primary and secondary outcomes will be described using proportions and means as appropriate, with confidence intervals. No formal comparisons will be made. The correlations between the voice outcome measures will be calculated. There is no planned interim analysis.

Enrollment: 23 patients

Sex: All

Ages: 18 to 70 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• UVFP due to unilateral recurrent laryngeal nerve paralysis of traumatic, iatrogenic or idiopathic origin of between 6 and 60 months duration. Or symptoms that have not sufficiently improved with speech therapy alone, as determined by the patient and agreed by a multidisciplinary clinical team, after 6 months and pending a surgical decision.
• Age from 18 to 70 years old
• Male or female
• Able to provide informed consent
• A significant voice disorder as measured by perceptual rating (Grade ≥2 GRBAS Scale) and Voice Handicap Index (VHI-10 score >16)
• Common laryngeal electromyography (EMG, neurophysiological) criteria (Koufman Grades 2-5) in either the thyroarytenoid (TA) or posterior cricoarytenoid (PCA) muscle on the paralysed side.

Exclusion criteria

• Impaired vocal fold mobility but a normal EMG (Koufman Grade I)
• Severe lung disorders
• Structural vocal fold lesions such as polyp
• Previous laryngeal framework surgery
• Cricoarytenoid joint fixation (CAJF)
• Significant non-laryngeal speech abnormality (severe dysarthria determined by a panel of trained speech therapists)
• Previous Level 2, 3 or 4 thyroid neck dissection
• Previous ipsilateral surgical neck dissection
• Previous radiotherapy to the head and neck
• Laryngeal injection of a rapidly absorbable material in the last 6 months.
• Previous laryngeal injection of a non-rapidly absorbable material (e.g. bioplastics, VOX)
• Neuromuscular disease affecting the larynx or multiple cranial nerve palsies

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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23 participants in 2 patient groups

Thyroplasty

Active Comparator group

Description:

This medialisation/augmentation technique is a static technique, performed under local anaesthesia that aims to improve the positioning of the paralysed vocal fold. It uses a silastic implant readily available in different sizes according to size of larynx and gender of the patient. The correct size can be determined intraoperatively by using a measuring device while listening and visualising the larynx with flexible fiberoptic scope simultaneously.

Treatment:

Procedure: Thyroplasty

Reinnervation

Active Comparator group

Description:

For laryngeal reinnervation, ansa cervicalis to recurrent laryngeal nerve repair technique will be used. In this technique, the functioning ansa cervicalis nerve that overlies the internal jugular vein and the distal stump of injured recurrent laryngeal nerve (RLN) will be identified and anastomosed without tension (Crumley RL. Teflon versus thyroplasty versus nerve transfer: a comparison. The Annals of otology, rhinology, and laryngology. 1990;99(10 Pt 1):759-63).

Treatment:

Procedure: Reinnervation