Current Understanding and Review of the Literature:

Vocal Fold Scarring

Jennifer K. Hansen and Susan L. Thibeault

Salt Lake City, Utah

Summary: Vocal fold scarring is the greatest cause of poor voice after vocal
fold injury. Scarring causes a disruption of the viscoelastic layered structure
of the lamina propria, an increase in stiffness of the vibratory structure, and
glottic incompetence. Current treatments for this complex condition are incon-
sistent and often produce suboptimal results. Research investigating this condi-
tion has dramatically increased over the last several years. The literature has
been directed toward understanding vocal fold scarring at the biological level
and translating this to the clinical forum. We present an up-to-date, thorough,
and scholarly review of the literature in vocal fold scarring since 1996.
Key Words: ScarringVocal foldsLarynxWound healing.

INTRODUCTION the literature is devoid of incidence and prevalence

Vocal fold scarring is the greatest cause of poor
voice after vocal fold injury.1 Scarring may cause
a deformity of the vocal fold edge, a disruption
of the viscoelastic layered structure of the lamina
propria, an increase in stiffness of the vibratory
structure, and glottic incompetence. Current clinical
management of this complex condition produces
inconsistent and suboptimal results. Even though
Accepted for publication December 20, 2004.
From the University of Utah, School of Medicine, Division
of Otolaryngology-Head and Neck Surgery, Salt Lake City, UT.
Supported by National Institutes of Health (NIH) Grant R01
DC4336 from the National Institute on Deafness and other
Communicative Disorders (NIDCD) and by NIH Grant T35
HL07744 from the National Heart Lung and Blood Institute
(NHLBI).
Address correspondence and reprint requests to Susan L.
Thibeault, University of Utah, School of Medicine, 50 N.
Medical Drive, 3C120, Salt Lake City, UT 84132. E-mail:
susan.thibeault@hsc.utah.edu
Journal of Voice, Vol. 20, No. 1, pp. 110120
0892-1997/$32.00
2006 The Voice Foundation
doi:10.1016/j.jvoice.2004.12.005
statistics for vocal fold scarring, it has been sug-
gested by Hirano2 that vocal fold scarring is one
major problem awaiting improvement in the
future. Consequently, research directed toward un-
derstanding vocal fold scarring in the basic science
and clinical arenas has increased considerably in
the past several years (Table 1). This review paper
serves to update the work published since
Benninger et al.3
The origins of the vocal fold scar include trauma,
radiation, and surgical treatment for neoplasms, iat-
rogenic causes, and inflammatory response to infec-
tion or injury in the airway tissues.3 When scar tissue
forms in the vocal fold lamina propria, the viscosity
and shear strength of the vocal fold changes such
that the normal mucosal wave is disrupted during
phonation. This disruption results in hoarseness, loss
of vocal control, and fatigue.4 The biomechanical
properties of the vocal folds are determined largely
by the relationship, density, and organization of the
extracellular matrix (ECM) components.4 Most
basic science research has focused on better under-
standing the constituents of the ECM, their distribu-
tion, and density during differing stages of wound
healing in the persistent scar. Clinical research has

110
 VOCAL FOLD SCARRING 111

TABLE 1. Summary of Recent Studies on Vocal Fold Scar

Type of Research Reference Outcome
4
Scarred rabbit vocal fold ECM Procollagen density increased
analysis at 2 months Collagen and elastin densities decreased
Viscosity and stiffness increased
No difference in HA levels

5
Scarred rabbit vocal fold ECM Collagen density increased
analysis at 6 months Elastin, procollagen and HA densities similar to controls

6
Scarred canine vocal fold ECM 2 months: Procollagen increased, elastin decreased
analysis at 2 and 6 months No difference in collagen and HA levels
6 months: Collagen increased, elastin decreased
Procollagen and HA densities were similar to controls

8
Scarred rat vocal fold ECM Re-epithelialization complete by day 14
analysis for days 114 HA depressed, present by day 3 and peaking at day 5
Fibronectin and collagen I present by day 1. Collagen III
present by day 3

9
Scarred rat vocal fold ECM HA levels depressed at all times measured
analysis at 2, 4, 8, and 12 weeks Collagen I and III elevated at all times measured
Fibronectin elevated for 4 weeks, control levels at 8 and 12 weeks

25
HA levels days 115 scarred Lower HA levels on days 3, 10, and 15
rabbit vocal folds No difference in HA levels on day 5 from control

7
HA and collagen levels in HA levels were lower days 3, 10, and 15
early stage wound healing in Collagen increased by day 15
pig vocal folds Phonation threshold pressure (PTP) higher
Vocal economy lower in injured larynges

13
Scarred rabbit vocal fold interstitial Interstitial proteins decorin and fibromodulin decreased
protein analysis at 2 months Fibronectin increased

14
Scarred canine vocal fold interstitial Fibronectin and Syndecan-4 increased at 2 and 6 months
protein analysis at 2 and 6 months Co-deposition of collagen with fibronectin observed at 6 months
Little or no activity from cadherin or syndecan-1

44
HGF activity in rat vocal folds and HGF and its receptor c-Met present on rat vocal fold epithelial and
injured rabbit vocal folds gland cells
Prominent HGF activity in injured rabbit vocal fold lamina propria
and epithelium on days 10 and 15

15
Effect of HGF, EGF, bFGF and TGFb1 HA production by fibroblasts was stimulated by HGF, EGF, BFGF,
on HA production by canine fibroblasts and TGFb1

27
Effect of HGF and TGFb1 on cultured HGF stimulated HA production, reduced collagen type I production,
canine vocal fold ECM and had no effect on fibronectin production
TGF b1 stimulated production of HA, collagen type I and fibronectin

28
Effect of HGF on human vocal fold HGF upregulated production of HA by FbRS. HGF downregulated
fibroblasts production of collagen type I by FbRS and FbMF

Continued
112 JENNIFER K. HANSEN AND SUSAN L. THIBEAULT
TABLE 1. Continued
Type of Research Reference
26
Anti-hyaluronidase activity of echinacoside
on human vocal fold fibroblasts and
injured pig vocal folds
29
Homologous collagen matrix injected into
scarred rabbit vocal folds
32
Analysis of scarred canine vocal folds treated
at time of injury with MMC
33
Analysis of injured canine vocal folds treated
4 days prior to injury with autologous MSC
34
Collagen treatment of scarred vocal folds:
prospective case study
43
Hylan B gel vs. collagen treatment for glottal
insufficiency, and hylan B gel treatment for
glottal insufficiency caused by scar defects
35
Autologous fat implantation for vocal fold scar
36
Autologous fat implantation into the vibratory
margin for vocal fold scar
37
Autologous fat implantation into the vibratory
margin for vocal fold scar
38
Autologous fascia implantation, followed by fat
injection for treatment of sulcus vocalis
examined the efficacy of traditional materials, ie, fat
and collagen and new biomaterials that may improve
both the biomechanical and the biological properties
of a vocal fold scar.
BASIC SCIENCE UPDATE
Treatment for vocal fold scarring is challenging
and amplified by a lack of knowledge regarding the
Journal of Voice, Vol. 20, No. 1, 2006
Outcome
HA production by fibroblasts is increased 24 hours after incubation
with echinacoside.
Topical Echinacea extract induced HA elevated levels and decreased
collagen deposition in pig vocal folds 3, 10, and 15 days
postoperatively
HCM stimulated production of procollagen with minimal
inflammation.
HCM did not improve the biomechanical properties of scarred
vocal fold.
At 2 and 4 weeks, treated vocal folds showed diminished connective
tissue response to surgical injury, with negative consequences
to the vocal fold vibratory pattern.
At 2 months, MSC treated vocal folds showed reduced fibrous
changes, reduced atrophy and growth of granulation polyps,
and no irregularity of surface, compared to controls
All patients had improved glottal area variations during vibration
after treatment
3 out of 4 patients had increased amplitude of vibration
Roughness was diminished in 2 out of 4 patients
Patients showed better vocal fold status and longer maximum
phonation time at 12 months after treatment with hylan B gel,
compared to patients treated with bovine collagen
Patients had improved vocal fold function and quality of
voice after injection with autologous fat
7 out of 13 patients showed improvement in vocal fold function,
2 showed failure after 2 and 3 months, 2 were lost to follow-up
and 2 had no change
Improvement in voice quality, mucosal wave and vibratory margin
motion were noted in some patients
Improvement in glottal closure, mucosal wave and amplitude,
breathiness and overall voice rating
specific histological structure of the scarred vocal
fold lamina propria. A comprehensive understanding
of the biology of vocal fold scarring provides a
foundation for future research that will address
scarring via a systematic approach. Subsequently,
systematic investigations have attempted to character-
ize wound healing and scarring in vocal fold lamina
propria ECM in a variety of animal models. An over-
view of this research can be found in Tables 2 and 3.
 VOCAL FOLD SCARRING
TABLE 2. Summary of Histologic Changes in Untreated Vocal Fold ECM Components After Injury
Injured Rabbit
Vocal Fold
ECM Component 3 day 5 day 10 day 15 day 2 mo 6 mo
Procollagen46
Collagen47,9,14,15
Elastin46
Fibronectin9,13,14
Decorin13
Fibromodulin13
Syndecan-114
Syndecan-414
Cadherin14
Hyaluronan47,9,15
increased level; decreased level; no change; similar to control; blank not measured.
COLLAGEN AND ELASTIN
Collagen in normal vocal fold tissue is organized
into bundles that run parallel to the epithelial mucosa
above it. Procollagen 1, a collagen precursor, and
elastin are also present in the superficial and deep
layers of the lamina propria of normal vocal folds,
respectively. Two months postoperatively, scarred
rabbit vocal fold tissue had elevated levels of procol-
lagen 1 in the superficial lamina propria.4 Collagen
is less dense and without its characteristic organiza-
tion into parallel bundles.4 Elastin is also less dense,
with fibers that were short and compact.4 By 6
months, levels of procollagen and elastin had re-
sumed the densities seen in normal vocal folds, al-
though the elastin fibers remain fragmented and
disorganized.5 Collagen densities, however, were
significantly higher than in normal vocal folds, again
with fibers organized into thick bundles.5 These
changes are thought to be indicative of the mature
phase of wound remodeling in rabbit vocal folds.
A canine model of vocal fold wound healing
showed similarities in procollagen 1, collagen, and
elastin levels with that of the rabbit model. Procolla-
gen 1 densities were elevated at 2 months, returning
to normal levels at 6 months.6 Elastin fibers were
fewer in number at both 2 and 6 months and seemed
tangled and disorganized. Collagen levels were not
significantly different at 2 months, but by 6 months,
collagen levels were elevated above that found in
normal vocal folds and showed marked disorganiza-
tion and thick bundling. Here again, vocal fold
113
Injured Canine Injured Pig Injured Rat
Vocal Fold Vocal Fold Vocal Fold
2 mo 6 mo 3 day 10 day 15 day 2 week 1 mo 2 mo 3 mo
scarring is characterized by elevated levels of pro-
collagen 1 in the early stage of wound healing, being
replaced by thick disorganized collagen bundles and
disorganized, fragmented elastin fibers in the later
stages of wound healing.
Collagen deposition in the very early stages of
vocal fold wound healing in a pig animal model
was studied and observed to be loose and sparsely
organized 3 and 10 days postoperatively in injured
and control tissues.7 On day 15, increased collagen
deposition and thick bundling was observed in the
scarred vocal folds only.
Finally, in a rat model, collagen type I and III
were elevated on day 1, with a more pronounced
elevation of collagen type III.8 Both collagen types
were elevated above controls at 2, 4, 8, and 12
weeks.9 Collagen type I levels declined after the
first 8 weeks of wound repair, although they were still
elevated above controls, which suggests that vigor-
ous tissue remodeling in the scarred vocal folds
slows after 2 months. Collagen type III levels
remained elevated and stable for the duration of
the study.
INTERSTITIAL PROTEINS
Fibronectin is an ECM glycoprotein that has been
shown to be an important adhesion molecule. Fibro-
nectin has properties that are chemotaxic for in-
flammatory cells and fibroblasts, and it contributes
to matrix organization.10 Fibronectin has been found
Journal of Voice, Vol. 20, No. 1, 2006
114 JENNIFER K. HANSEN AND SUSAN L. THIBEAULT
TABLE 3. Summary of Biomechanical Changes Found in Rabbit and Canine Vocal Folds
Dynamic Viscosity
Animal Model (h)
2-month scarred rabbit vocal fold4
6-month scarred rabbit vocal fold5 * *
2-month scarred canine vocal fold6
6-month scarred canine vocal fold6
15-day injured pig vocal fold7
increased level; decreased level; blank not measured.
*Values not statistically significant.
to be overexpressed in hypertrophic11 and chronic
wounds,12 and its persistence above normal levels
in the ECM may contribute to fibrosis at the site of
wound repair.13 Fibronectin in normal vocal fold
tissue is found primarily in the basement membrane
zone and in the superficial layer of the lamina pro-
pria.1416 Levels of fibronectin in scarred vocal fold
tissue were studied in rabbit and canine models.13,14
It was found that levels of fibronectin in 2-month
scarred rabbit vocal fold tissue were significantly
increased over normal vocal fold levels, with more
prominent staining patterns observed in the superfi-
cial lamina propria. Similarly, in scarred canine
vocal folds, fibronectin was found at significantly
higher levels in the superficial lamina propria at 2
months, and it continued to be higher 6 months
postoperatively. These increased levels imply that
even as late as 6 months after injury, matrix reorgani-
zation, stimulated at least in part by fibronectin,
continues in the superficial layer of the lamina pro-
pria, with likely resultant increases in fibrosis and
collagen deposition characteristic of scar tissue.
The vocal fold scar in the rat was shown to have
increased levels of fibronectin until the fourth week
of wound healing, whereafter levels declined, reach-
ing control levels at 8 and 12 weeks.9 These fluctua-
tions in levels of fibronectin corresponded roughly to
levels of collagen type I found in the same tissues,
which reinforces the probable relationship between
fibronectin and collagen in wound repair.
Decorin is a small-chain proteoglycan adhesion
molecule present in the ECM that attaches to colla-
gen and maintains collagen fibril organization.17 De-
corin has been previously identified in the superficial
lamina propria and may contribute to the minimal
Journal of Voice, Vol. 20, No. 1, 2006
Elastic Sheer Phonation Threshold Vocal Economy (Acoustic
Modulus (G) Pressure (PTP) Output Cost Ratio, OCR)
scarring observed when this layer of the lamina pro-
pria is disturbed.17,18 It has been shown in previous
studies that decorin regulates collagen assembly in
the ECM, which influences its rate of formation and
the thickness of fibrils.17,18 It is possible that if ade-
quate levels of decorin could maintain collagen fibril
organization, the thick bundling and disorganized
structural regrowth characteristic of scar tissue
could be avoided when the deeper layers of the lamina
propria are disturbed. Decorin density in scarred
rabbit vocal folds 60 days after injury was signifi-
cantly decreased.13 As decorin is thought to promote
the lateral association of collagen fibrils to form
organized collagen bundles, decreased levels of de-
corin would lead to regeneration of tissue with an
unorganized collagen matrix, and it has been re-
ported for the acute vocal fold scar.4
Fibromodulin is an ECM proteoglycan that
binds and potentially inhibits transforming growth
factor beta (TGF-), and it has been found primarily
in the intermediate and deep layers of the lamina
propria, in association with collagen and elastin
fibers of the vocal ligament.17,18 Fibromodulin inhib-
its transforming growth factor beta (TGF-), which
upregulates collagen synthesis. Thus, decreased
levels of fibromodulin would be expected to occur
in conjunction with increased collagen synthesis. It
has been shown that procollagen is increased 2
months after scar formation4 concomittantly with a
significantly decreased level of fibromodulin with
distribution of fibromodulin mainly in the superficial
lamina propria.13 Decreased fibromodulin in the su-
perficial lamina propria could lead to increased col-
lagen synthesis in this layer of the vocal fold as
the wound heals. Collectively, decreased levels of
 VOCAL FOLD SCARRING
decorin and increased fibronectin would be expected
with elevated levels of collagen synthesis (due to
decreased fibromodulin), disorganized collagen de-
position (due to decreased decorin), and continued
inflammatory cell and fibroblast migration (due to
increased fibronectin). These correlations are sup-
ported by recent studies in a rabbit model.4,15
The dynamic association between fibronectin and
collagen was observed in scarred canine vocal folds
by Hirano et al.15 Fibronectin, but not collagen,
was observed at increased levels in 2-month scar
tissue. At 6 months, both fibronectin and collagen
levels were significantly increased above normal
levels. This increase suggests that replacement of
fibronectin by collagen is a prolonged process and
not evident until sometime after the 2-month postop-
erative period and continuing through the 6-month
postoperative period. Although some elevated levels
of fibronectin are necessary for the regeneration of
vocal fold tissue after injury, manipulation of fibro-
nectin levels may in turn affect the deposition of
collagen in the later stages of wound healing and
reduce the subsequent scarring seen in the vocal
folds after injury.13
Density and distribution of other adhesion mole-
cules, namely cadherin, syndecan-4, and syndecan-
1, were measured in normal versus scarred canine
vocal folds.15 Syndecan-4 was rarely found in the
normal vocal fold epithelium, but it was prominently
expressed in the basal layer of the mucosal epithe-
lium of scarred vocal folds, 2 months and 6 months
postoperatively. Levels of syndecan-1 and cadherin,
adhesion molecules found in the epithelial inter-
cellular space, were detectable but unchanged in
normal versus scarred vocal fold tissue. From these
studies, it seems that the basal layer of the mucosal
epithelium continues to experience remodeling in
the later stages of wound healing, whereas the
intercellular epithelial space undergoes remodeling
earlier during the acute stage of wound healing.
HYALURONAN
A way to preserve normal collagen architecture in
wound healing may eventually be found in the
extracellular and intracellular signaling properties
of glycosaminoglycans (GAG) in the ECM. Hyalur-
onan (HA) is a nonantigenic GAG polysaccharide
115
found in the ECM throughout the body and concen-
trated in the vocal folds and other specialized tis-
sues.19 Higher concentrations of HA are found in
the infrafold region of the vocal fold, which corres-
ponds to the region where the mucosal wave
begins its vertical rise.18 It has been shown that if
HA is removed from the vocal folds, there is an in-
crease in viscosity and a reduction in stiffness of the
tissue, which creates less than optimal conditions for
phonation and vocal fundamental frequency.20,21 In
general, men have a higher concentration of HA
in the vocal folds than do women.22
Levels of HA in the vocal folds may have an
impact on wound healing and scar formation. Ex-
ploring the phenomenon of fetal scarless wound
healing, sheep fetal wound fluid has been found to
contain significantly higher levels of HA than adult
wounds, which suggests that HA has a mechanistic
role in wound healing.23 It has been shown that in
dermal wound healing, a chemically cross-linked
HA hydrogel film and a chondroitin sulfate hydrogel
film promoted reepithelialization, vascularization,
and dermal collagen organization.24 GAG films may
retain cytokines and other growth factors made by the
regenerating tissue, which facilitates the assembly
of other matrix components and supports cell migra-
tion to the wound site.
Research has been completed to learn more about
the role of HA in the vocal fold repair process. The
density and distribution of HA in scarred vocal
folds has been compared with normal vocal folds
in rabbits and canines. Measured levels of HA in
injured rabbit vocal folds during the early stages of
wound repair were lower than normal during the
first 15 days of wound healing.25 Postoperatively,
day 3 injured vocal folds showed significantly lower
levels of HA than normal vocal folds. Day 5 was
the only time during the 15 days that HA levels in
scarred tissue were comparable with controls. Thus,
even in the early stage of wound repair in the mature
rabbit, HA levels were never elevated above that
found in undisturbed tissue, and they were actually
lower than normal, overall, during most of the first
15 days. HA levels in the acute stage of wound
healing were studied in a pig model with similar
results being reported. HA levels were reduced in
the injured pig vocal folds 3, 10, and 15 days postop-
eratively compared with controls.7 In the rat model,
Journal of Voice, Vol. 20, No. 1, 2006
116 JENNIFER K. HANSEN AND SUSAN L. THIBEAULT
it was found that HA levels were lower than controls,
although there was evidence of HA in the tissues by
day 3 and peaking at day 5. Because collagen and
fibronectin levels were found to peak at days 3 and 5
as well, HA may have a role in the regulation or
deposition of collagen in the acute phase of wound
healing.8 However, this hypothesis requires more
investigation as HA levels were depressed in scarred
rat vocal folds when measured at 2, 4, 8, and 12
weeks, even as levels of collagen types I and III
were elevated.9
It has been shown that the density of HA in the
scarred vocal folds at 2 and 6 months postoperatively
is not statistically different from normal vocal folds
in either the rabbit or the canine model.46 The distri-
bution of HA in normal rabbit vocal folds is predom-
inantly in the deep lamina propria, similar to the
distribution of HA in normal canine vocal folds.
After scarring, rabbit vocal folds show a redistribu-
tion of HA to all layers of the lamina propria, when
viewed 2 and 6 months postoperatively.4,5 In
contrast, scarred canine vocal folds show no redistri-
bution of HA to other layers of the lamina propria
after wounding.6 Because these studies have shown
that HA levels in scarred vocal folds 2 and 6 months
postoperatively are the same as controls, it is thought
that the critical time frame for the involvement of
HA in wound repair occurs earlier in the wound
repair stage, in the first few days and weeks after
injury.4,5
Endogenous HA is rapidly turned over in the body,
and its half-life in the vocal fold tissues has been
estimated to be between 0.5 and 4 days.26 The
turnover of HA is accomplished by hyaluronidases
that enzymatically degrade HA intracellularly after
it has been removed from the ECM by receptor-
mediated endocytosis.19 By inhibiting the hyaluroni-
dases, it is possible to keep HA at normal levels in
the early stages of wound healing.26 Echinacoside, a
caffeoyl derivative and known anti-hyaluronidase
from the Echinacea plant, was added to human
vocal fold fibroblast cell lines; incubated for 24, 48,
or 72 hours; and then analyzed for HA concentration.
Higher levels of HA were found in the supernatant
of the treated cells that had been incubated for 24
hours than were found in controls, presumably
because of anti-hyaluronidase activity, and not
Journal of Voice, Vol. 20, No. 1, 2006
because of stimulation of HA production. No ele-
vated levels of HA were found in samples treated
and incubated for 48 or 72 hours, which warrants
additional study.
GROWTH FACTORS AND
ANTI-HYALURONIDASES
The importance of the role of HA in the biomecha-
nics of the vocal folds has led to research that seeks
to broaden the understanding of factors that influ-
ence HA levels in normal tissue and in the wound
healing process. A two-part study determines which
growth factors influence the production of HA by
canine vocal fold fibroblasts in vitro and how mainte-
nance of high levels of HA can be stimulated by
repeated administration of growth factors.15 The
growth factors were hepatocyte growth factor
(HGF), epidermal growth factor (EGF), basic fibro-
blast growth factor (bFGF), and transforming growth
factor beta 1 (TGF1). Growth factor was adminis-
tered to cell cultures according to different predeter-
mined schedules: (1) day 1 only; (2) days 1 and 4;
(3) days 1, 3, and 5; or (4) daily for 6 days. The
results of the first study showed that all growth
factors significantly increased HA synthesis. The
second study showed that a single administration of
EGF, bFGF, and TGF1 on day 1 was sufficient to
increase HA production for at least 7 days. HGF
increased HA production in all variations of admin-
istration except when given on schedule at days 1
and 4.
The localization and activity of HGF and its recep-
tor, c-Met, in fibroblasts in the ECM of rat and
rabbit vocal folds were studied to substantiate their
existence.27,44 Normal rat vocal folds were found
to express HGF and c-Met in the epithelial and
gland cells, but not in the lamina propria and muscle
at significantly detectable levels. Injured rabbit vocal
folds, with a section of epithelium removed, showed
no HGF in the lamina propria initially, but by day
5 and peaking at day 10, they showed the presence of
HGF in the regenerating epithelium, lamina propria,
and gland cells. The study did not address whether
the HGF is produced by fibroblasts in the lamina
propria and transported to the epithelium or whether
HGF is produced by the epithelial cells in an auto-
crine fashion. The results of this study suggest that
 VOCAL FOLD SCARRING
HGF has an antifibrotic role in the healing of vocal
fold wounds, similar to its role in other organs. An
in vitro study of HFG stimulated canine vocal fold
fibroblasts to increase production of HA and to de-
crease production of collagen type I.27 The produc-
tion of fibronectin was not affected by HGF.
Consequently, stimulation of canine fibroblasts with
TGF1 not only increased levels of HA, but also
increased levels of collagen type I and fibronectin.
The in vitro effects of HGF on human vocal fold
fibroblasts from the macula flava (FbMF) and the
Reinke space (FbRS) were studied.28 It was shown
that stimulation by HGF upregulated production of
HA by FbRS, downregulated production of collagen
type I in both cell types, and had no effect on fibro-
nectin production by either cell type. HGF also had
an effect on cell shape and organelle development
in FbRS. More well-developed Golgi apparatus
and rough endoplasmic reticulum were observed in
FbRS with added HGF, and the shapes of the cells
shifted from oval toward spindle and stellate. Organ-
elle development and cell shape showed little change
in FbMF when HGF was added. These results
suggest that HGF has a greater effect on the FbRS
and may be a potential for future treatment avenues
for scarring.
TREATMENT UPDATE: ANIMAL STUDIES
Animal studies have focused on either treatment
of the mature scar or on minimizing the scar by
treatment at the time of injury. Improvements in
the biomechanical properties have been the main
outcome assessed with rheological, stroboscopic, or
acoustic methodologies. Tissue histology has been
reported mainly to describe the fate of the augmented
material. This literature is void of data verifying
improved tissue genotype or phenotype.
An injectable homologous collagen matrix
(HCM) was assessed as a potential candidate to treat
the mature scar of the lamina propria by Kriesel
et al.29 Histological analysis 10 weeks after injection
demonstrated HCM globules distributed throughout
all layers of the vocal foldmuscle and lamina
propria. Higher quantities of procollagen 1 were
measured in the treated vocal folds, which suggests
tissue remodeling. HCM was found to be non-
immunogenic; it did not become incorporated into
117
the surrounding tissues nor become infiltrated by
surrounding cells. Because the biomechanical
properties of the injured lamina propria were not
improved, in combination with the histological fate
of the material, HCM may be more appropriate for
injection into the thyroarytenoid for medialization,
rather than for restoration of the ECM of the
lamina propria.
Because of the ubiquitous role of HA in wound
healing, maximizing HA levels at the time of injury
is a promising line of study. Rousseau et al26 investi-
gated echinacoside, an anti-hyaluronidase in a pig
model. Treated vocal folds were found to have in-
creased levels of HA over untreated injured vocal
folds, with levels similar to uninjured controls on
all postoperative days, measured histologically.
Collagen accumulation in the scarred vocal folds
was reduced compared with untreated vocal folds.
Biomechanically, the treated larynges demonstrate
lower phonation threshold pressure and improved
vocal economy.
Hirano et al30,31 have studied the effect of HGF
at the time of intentional injury in the rabbit and
canine model. In both studies, treated vocal folds
had improved biomechanical properties with less
collagen deposition and tissue contraction. Unfortu-
nately, HA levels were not measured in either study.
And the mechanism for improvement can only be
speculated.
Mitomycin-C (MMC), an antiproliferative, has
been assessed on vocal fold wound healing in ca-
nines.32 MMC has been shown to inhibit fibroblast
proliferation and scar formation in clinical settings,
and it was hypothesized that MMC applied topically
at the time of surgical injury to the vocal folds
would reduce fibrosis that contributes to permanent
dysphonia. Conversely, MMC-treated vocal folds
became atrophic and deficient in the lamina propria
compared with controls. The vocal fold vibratory
pattern measured by stroboscopy showed either no
change or decreased mucosal wave capabilities com-
pared with controls. Histological analysis showed
that MMC-treated vocal folds had fewer fibroblasts
and less collagen in the lamina propria than did the
controls. Additional investigation is necessary to
determine whether MMC can play a role in the
treatment of vocal fold scarring.
Journal of Voice, Vol. 20, No. 1, 2006
118 JENNIFER K. HANSEN AND SUSAN L. THIBEAULT
Lastly, a unique study investigated the effects of
autologous mesenchymal stem cells (MSC), which
were harvested from the bone marrow and injected
4 days before the time of injury to the vocal folds
in canines.33 Morphologically, vocal folds treated
with MSC showed fewer irregularities, fewer granu-
lation polyps, and less fibrotic change and atrophy
than did the controls. Histological staining showed
that MSCs were actively involved in the regenera-
tion of the damaged tissues. No biomechanical
measurements were reported. MSC has showed
promise in other areas and warrants continued
investigation.
HUMAN CLINICAL TRIALS UPDATE
There have been a few clinical studies that investi-
gated treatment for vocal fold scarring. Furthermore,
work to date has not capitalized on the basic sci-
ence and animal research in the literature, in part,
because of the time lag in the translation of basic
science to the clinical realm and because of the
limited biomaterials that are available and approved
for human use. One would expect newer materials
to be available to the clinician before long, given the
volume of research being undertaken at the basic
science and animal trial levels. To date, published
clinical trials have focused on collagen, fat, fascia,
and in Europe, HA.
A prospective case study by Bjorck et al34 on four
human patients who had received collagen (Zyplast)
injections showed that collagen may soften stiffened
vocal folds. This conclusion was based on follow-
up evaluations performed between 6 months and 17
months after Zyplast injection. Improvements were
noted in amplitude of vibration, glottal closure, and
glottal area variations during vibration. However,
these improvements in vocal fold movement were
not translated to perceptual or acoustic analyses.
Inconsistent improvements have been reported in
the literature with fat injections. Neuenschwander
et al35 reported the results of a retrospective study
of eight patients who had received autologous fat
implantation in the vocal fold margin for treatment of
dysphonia related to the vocal fold scar. Acoustic
improvements, as measured by the GRBAS, were
reported. Improvements were also measured in glot-
tic closure, mucosal wave, and stiffness. Length of
Journal of Voice, Vol. 20, No. 1, 2006
scar or degree of ectasia did not improve with fat
injections. In a study by Hsiung et al,36 patients with
a vocal scar received an injection of autologous fat
into the vibratory margin of the vocal fold. The
results of acoustic and phonatory function, GRBAS
evaluation, and videolaryngostroboscopy (VLS) of
the vocal scar patients were averaged with the results
of patients with origins of vocal cord paralysis and
vocal atrophy. Results showed a mean increase in
fundamental frequency and phonatory time and a
decrease in jitter, shimmer, and noise-to-harmonic
ratio. There was an overall improvement in grade,
asthenia, and breathiness, but no improvement of
statistical significance in roughness or strain. VLS
results showed significant changes in vocal fold
edge, amplitude, mucosal wave, vibration behavior,
phase symmetry, and glottic closure. Specific results
for the vocal fold scar treated group were not re-
ported. Preliminary results on four patients who
received autologous fat implantation into the vibra-
tory margin of the vocal folds as treatment for scar-
induced dysphonia were reported by Sataloff et al.37
Stroboscopic results showed improvement in all pa-
tients in symmetry of amplitude and phase, glottic
closure, amplitude and wave of implanted fold,
adynamic segment, and either improvement or no
change in periodicity. A combination of autologous
fat and fascia treated 22 patients with sulcus
vocalis, with overall excellent results, by Hsiung
et al38 Improvements were measured stroboscopi-
cally for glottal closure, mucosal wave and am-
plitude, breathiness, and overall voice rating.
HA, although endogenous in normal and scarred
vocal fold tissue, has a short half-life39 and may
not be present for an adequate length of time or in
sufficient quantities to benefit healing of the vocal
folds after trauma.25 However, cross-linked HA
has shown promise as an injectable agent because
of its longer residence time and nonantigenicity.40
Hylaform (Hylan B) is a viscoelastic, nonpyrogenic
cross-linked hyaluronic acid gel currently on the
market as a dermal filler that has also been shown to
have a longer residence time in vocal fold tissue.40,41
Rabbit vocal folds injected with hylan B had no
inflammatory reactions 1, 3, 6, or 12 months after
injection.42 By 12 months, loose connective tissue
rich in collagen and HA had grown into the gel with
the presence of granuloma in the tissue. Hertegard
 VOCAL FOLD SCARRING
et al43 compared cross-linked HA (hylan B gel) with
bovine collagen for randomized injection augmen-
tation in human patients who had glottal insuffi-
ciency because of scar defects or paresis resulting
from malignant disease. Results were measured by
VLS and by the subjective ratings of voice functions
of patients. Glottal closure improved for both the
hylan B gel and the collagen groups, but vibration
amplitude and glottal area variations were preserved
in the hylan B gel group only. Patients injected with
hylan B gel had less resorption of the bolus at the
injected vocal fold edge and increased maximum
phonation time than had patients injected with colla-
gen. One patient injected with hylan B gel showed
improvement in all glottal closure and vibratory
capacity parameters 12 months after treatment.
CONCLUSION
To establish more effective treatment for vocal
fold scarring and the resultant devastating dyspho-
nias, a more thorough understanding of the under-
lying abhorrent wound healing mechanisms are
required. Basic science and animal research in this
area has intensified since the influential review of
Benninger in 1996. This work will direct future
translational clinical trials, such that the best materi-
als that optimize biomechanical properties and
mimic the ECM lamina propria biologically can be
assessed systematically. Successful treatment and
management of vocal fold scarring will depend on
critical cooperation and collaboration between basic
scientists and laryngologists.
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