Materiały źródłowe

• #1 A Study of incidence and etiopathology of vocal cord paralysis

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3450463/

  Vocal cord paralysis is not a disease per se but is considered as a sign of underlying disease process that may be congenital or acquired, unilateral or bilateral, sudden or gradual in onset, and may occur at any age from cradle to the grave. […] This study was carried out to know the incidence and etiopathology of vocal cord paralysis. The incidence was 0.42% or 42 per ten thousand new patients seen. Most patients presented in the 5th and 6th decades (77.2%). Males outnumbered females in the ratio of 3:1. The most common symptom of vocal cord paralysis was hoarseness of voice alone (83.6%). Onset of symptoms was gradual in 60% of cases. Left vocal cord was almost twice more commonly (61.9%) involved than the right one (38.1%). Idiopathic group constituted 38.18% of patients followed by neoplastic diseases 29.09%.

• #2

  https://link.springer.com/article/10.1007/s00405-013-2655-1

  Although surgical treatment of patients with chronic vocal cord palsy (VCP) is an integral part of clinical routine of otorhinolaryngologists, there is nearly no population-based data published on incidence and efficiency of this surgery country-wide or nation-wide. 1430 patients with chronic VCP were treated in a department of otorhinolaryngology between 2005 and 2010 in Thuringia, Germany. The rate of patients admitted for treatment of vocal fold palsy was 9.9/100,000 habitants. The surgical rate of VCP was 1.38/100,000 habitants. This population-based analysis shows that surgery for VCP is performed with higher incidence than expected effectively, but with relevant risks in daily routine of otorhinolaryngologists. […] Iatrogenic lesions of the recurrent nerve (42 %) and neoplastic infiltration (27 %) were the leading etiologies. 192 patients (13 %) received surgical treatment. 31 % of patient needed more than one surgery. The rate of surgeries was higher for bilateral VCP (p 0.0001). The complication rate was high (16 %), but not different between unilateral and bilateral VCP (p = 0.108). The risk for tracheostomy was higher in the bilateral VCP group (p 0.0001). Voice improvement was better after treatment of unilateral VCP (p 0.0001). Breathing improvement was more frequent after bilateral VCP (p= 0.028). Dysphagia did not improve significantly. The rate of better voice, breathing, and swallowing function was higher in patients treated surgically than without surgery (all p 0.0001).

• #3 Therapy of bilateral vocal fold paralysis: Real world data of an international multi-center registry | PLOS One

  https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0216096

  Bilateral vocal fold paralysis (BVFP) is a rare disease with an approximate incidence of 0.95 cases per 100,000 persons. […] Since this disease occurs so seldom, there is a lack of standardized protocols and outcome measures for its diagnosis, treatment and follow-up and consequent high variability among the handling approaches across the various hospitals. […] This first publication focuses on the evaluation of the results and complications of BVFP surgical treatments, based on retrospective data collected across 11 sites in Europe. […] The registry aims to collect real-life data concerning BVFP epidemiology, diagnosis, treatment, patients management, and impact of the disease on the quality of life before and after treatment. […] The registry procedures and documentation comply with the principles of the Clinical Practice Guidelines, in particular of the ISO 14155:2011, and the Declaration of Helsinki.

• #4 Bilateral Vocal Cord Paralysis – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK560852/

  As the primary cause of bilateral vocal cord paralysis is post-surgical nerve injury, it is predominantly seen in adults with a history of thyroid or other bilateral neck surgery. Idiopathic causes may show a slight female predominance, but there is no high-quality data published on this subject at this time. […] Although uncommon, vocal cord paralysis is a well-known cause of stridor in neonates, most congenital cases are unilateral. Murty et al. estimate the incidence of bilateral vocal cord paralysis to be 0.75 cases per million births per year. Neonatal bilateral vocal cord paralysis rarely occurs in isolation; factors such as prematurity and bronchopulmonary dysplasia often coexist, in addition to neurologic abnormalities that can lead to worse outcomes in infants. Congenital vocal cord paralysis should be part of the differential diagnosis for an infant with respiratory distress.

• #5 Isolated neonatal bilateral vocal cord paralysis revealing a unilateral medullary defect: a case report | BMC Pediatrics | Full Text

  https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-018-1329-y

  Bilateral vocal cord paralysis (BVCP) is very rare in the neonate, with the incidence estimated at 0.75 cases per million births per year. […] The series focused on congenital BVCP have highlighted two fairly well-balanced aetiological groups: one idiopathic and the other associated with major comorbidities. […] This case also highlights the help provided by advanced neuroimaging techniques, i.e. fibre tracking using diffusion tensor imaging, in the decision-making process. […] The prognosis of brainstem disconnection is generally very poor, with respiratory failure occurring soon after support is removed. […] An isolated BVCP in a neonate can be caused by a medullary defect, a very rare congenital anomaly. This case report contributes to the phenotypic description of this poorly understood entity, here characterized by a strictly unilateral neurological and vascular defect and the absence of associated malformation.

• #6 Bilateral Vocal Cord Paralysis – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK560852/

  Following laryngomalacia, vocal cord paralysis is the second most common congenital laryngeal abnormality in the pediatric population (with the vast majority being unilateral paralysis), likely due to improved survival of premature infants and infants with complex congenital abnormalities. […] In up to 48% to 62% of all-aged children with bilateral vocal cord paralysis, spontaneous recovery of vocal cord function can occur, but the prognosis rests with the overall health of the child and any concomitant medical problems.

• #7 Vocal Cord Paralysis | Children’s Hospital of Philadelphia

  https://www.chop.edu/conditions-diseases/vocal-cord-paralysis

  Vocal cord paralysis is the second most common congenital defect of the larynx (voice box), accounting for about 10 to 15 percent of congenital laryngeal disorders. […] Our voice team at The Childrens Hospital of Philadelphia is a dynamic multidisciplinary group of professionals with years of experience managing pediatric voice difficulties. We have one of the largest populations of pediatric patients with unilateral vocal cord paralysis who come from all over the world to our voice clinic for surgical management and voice rehabilitation.

• #8 Vocal Cord Paralysis – Ear, Nose, and Throat Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/ear-nose-and-throat-disorders/laryngeal-disorders/vocal-cord-paralysis

  Vocal cord paralysis has numerous causes and can affect speaking, breathing, and swallowing. The left vocal cord is affected twice as often as the right, and females are affected more often than males (3:2). Diagnosis is based on direct visualization. An extensive assessment may be necessary to determine the cause. Several direct surgical approaches are available if treating the cause is not curative. […] Vocal cord paralysis may result from lesions or dysfunction at the level of the nucleus ambiguus, its supranuclear tracts, the main trunk of the vagus, or the recurrent laryngeal nerves. The left vocal cord is paralyzed more often than the right because the left recurrent nerve takes a longer course from the brain stem to the larynx, providing more opportunity for compression, traction, or surgical injuries.

• #9 Vocal Cord Dysfunction: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/137782-overview

  This condition is predominantly observed in females. The authors’ review of the published literature indicates a female-to-male ratio of approximately 3:1. This condition predominates in people aged 20-40 years, but it can occur in people aged 6-83 years. Recent literature suggests an increase of this condition in children and adolescents.

• #10 Vocal Cord Paralysis – Ear, Nose, and Throat Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/ear-nose-and-throat-disorders/laryngeal-disorders/vocal-cord-paralysis

  Diagnosis of vocal cord paralysis is based on laryngoscopy. The cause must always be sought. Evaluation is guided by abnormalities identified on history and physical examination. […] Vocal cord paralysis can be caused by a lesion or dysfunction anywhere in the neural pathway to the larynx (the nucleus ambiguus, its supranuclear tracts, the main trunk of the vagus, the recurrent laryngeal nerves). Most paralyses are unilateral and affect mainly the voice, but bilateral paralysis can occur and obstruct the airway. Paralysis is diagnosed by laryngoscopy, but identification of the cause typically requires imaging (eg, MRI) and other tests. Patients with bilateral paralysis often require tracheal intubation/tracheotomy initially, before corrective surgical procedures are attempted. Various surgical procedures are available to improve voice quality in unilateral paralysis or to improve airway patency in long-term bilateral paralysis.

• #11 Vocal Cord Paralysis Evaluation and Etiology | Iowa Head and Neck Protocols

  https://medicine.uiowa.edu/iowaprotocols/vocal-cord-paralysis-evaluation-and-etiology

  Population based study from Germany (Djugai 2014) […] 1430 patients with vocal cord paralysis (VCP) – both uni- and bi-lateral treated in Thuringia, Germany 2005-2010 […] 42% Iatrogenic / 27% Neoplastic Infiltration. […] Chronic vocal cord palsy in Thurigngia, German: a population based study on epidemiology and outcome. Eur Arch Otorhinolaryngol 2014 Vol 271, Issue 2, Pages 32935.

• #12 Vocal Fold Paralysis (Vocal Cord Paralysis) Etiologies | Iowa Head and Neck Protocols

  https://medicine.uiowa.edu/iowaprotocols/vocal-fold-paralysis-vocal-cord-paralysis-etiologies

  „Vocal fold paralysis is not a rare clinical entity.” Sulica and Blitzer 2006 […] Overall incidence/prevalence of laryngeal paralysis in the United States and the world is not known. Difficulties in determining this information include: […] Detection of laryngeal paralysis requires imaging of the larynx […] Detection of laryngeal paralysis by reporting of symptoms by the patient (without examining the larynx) markedly under estimates the extent of the problem […] A survey of cases Otolaryngologists in the United States by Rosen C (1998) […] Followup survey of Otolaryngologists in the United States (Young et al 2010) […] Well differentiated thyroid cancer responsible for 50% of the 80,000 thyroidectomies done in the U.S. annually (Francis D et al 2014) […] 9.5% complicated by vocal fold paralysis (8.2% unilateral; 1.3% bilateral)

• #13 Bulking Agents for the Treatment of Vocal Cord Paralysis

  https://www.southcarolinablues.com/web/public/brands/medicalpolicy/external-policies/bulking-agents-for-the-treatment-of-vocal-cord-paralysis/

  Vocal cord paralysis may be unilateral or bilateral, central or peripheral. Unilateral left vocal cord paralysis is most common. Less than 20% of cases are bilateral. Thyroidectomy is by far the most common cause of bilateral vocal cord paralysis. Central causes include brain stem and supranuclear lesions and account for only 5% of all cases. […] Most cases of peripheral vocal cord paralysis are secondary to thyroidectomy or non-laryngeal neoplasms, including bronchogenic, esophageal and thyroid carcinoma. […] In adults, unilateral recurrent laryngeal nerve paralysis generally produces hoarseness and a weak, breathy voice with varying amounts of aspiration. […] Bilateral vocal cord paralysis is commonly associated with inspiratory stridor, shortness of breath and dyspnea on exertion.

• #14 Vocal Cord Paralysis | IntechOpen

  https://www.intechopen.com/chapters/81705

  Vocal cord paralysis can be due to neurogenic cause, trauma due to surgery, or mechanical fixation of the cords. […] The incidence of the bilateral vocal cords paralysis comprises around one-third of all vocal cord paralysis cases. […] Studies on comparison of patient demographics show no statistically significant difference in age, gender, or duration of symptoms. […] As bilateral vocal cord paralysis occurs most commonly after iatrogenic trauma to recurrent laryngeal nerve, there is history of recent thyroid surgery in these patients. The incidence of the bilateral vocal cords paralysis comprises around one-third of all vocal cord paralysis cases. […] It requires interprofessional team of otolaryngologists, radiologists, and speech therapists in the evaluation and management of vocal cord paralysis.

• #15 Vocal Cord Paralysis Treatment NYC | Mount Sinai – New York

  https://www.mountsinai.org/locations/grabscheid-voice-swallowing-center/conditions/vocal-cord-paralysis

  Vocal cord paralysis occurs when the nerve impulses to your voice box (larynx) are interrupted. This results in paralysis of your vocal cord muscle. Vocal cord paralysis can affect your ability to speak and even breathe. […] There are a number of causes of vocal cord paralysis, including nerve damage during surgery and certain cancers. Vocal cord paralysis can also be caused by a viral infection or a neurological disorder. […] Factors that may increase your risk of developing vocal cord paralysis include: […] Undergoing throat or chest surgery. Thyroid, throat, or upper chest surgery increases your risk of vocal cord nerve damage. […] Having a neurological condition. Certain neurological conditions, such as Parkinson’s disease, multiple sclerosis or myasthenia gravis, may cause vocal cord weakness or paralysis. […] Treatment of vocal cord paralysis depends on the cause, the severity of symptoms, and the time from the onset of symptoms. Treatment may include voice therapy, surgery, or both.

• #16 Therapy of bilateral vocal fold paralysis: Real world data of an international multi-center registry | PLOS One

  https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0216096

  The most common etiology was thyroid surgery (60.4%). […] 201/326 (61.7%) of the patients received a surgical treatment at baseline. […] The average inpatient treatment duration for any kind of BVFP treatment or for BVFP-related complications was 8.4 9.6 days. […] The most frequent surgical approach was the one-sided glottal enlargement (46.3%). […] The decannulation rate of at baseline tracheotomized patients was 33.8% and 38.2% at 24 and 48 months, respectively. […] Considering all the patients included retrospectively in the registry, forty-six (46) revision surgeries were required in the 2-year follow-up period after the first surgery, which implies a revision rate of 32.4%. […] Alcohol drinking habits and cancer etiology of the BVFP were significant risk factors for revision need.

• #17 APPROACH TO A PATIENT WITH VOCAL CORD PARALYSIS | PPT

  https://www.slideshare.net/slideshow/vocal-cord1/52472043

  9. Radiological chest xray:- secondaries, primary carcinoma, apiration pneumonia, metastatic lymph nodes, aortic arch aneurysm and TB. (54% diagnostic yield) No other detectable lesion: contrast CT ( skull base to aortic arch) No mass lesion idiopathic. Palatal pharyngeal paralysis and other neuropathies: gadolinium enhanched MRI skull base and neck. If negative- HRCT temporal bone for bony mets […] 10. Treatment Unilateral vocal fold palsy Known permanent etiology/ unknown etiology 9 months Healthy pt, no aspiration Healthy pt, with aspiration sick pt, with or w/o aspiration VOICE THERAPY PHONOSURGERY […] 11. Temporary or unknown etiology 9 months Healthy pt,no aspiration Healthy pt,with aspiration strong need of voice sick pt, with or w/o aspiration VOICE THERAPY TEMPORARY AUGMENTATION after 9 months DEFINITE PHONOSURGERY

• #18 Etiology and presenting features of vocal cord paralysis: changing trends over the last two decades | The Egyptian Journal of Otolaryngology | Full Text

  https://ejo.springeropen.com/articles/10.1186/s43163-022-00322-x

  The study was performed to evaluate the changing trends in etiology and presenting features of vocal cord paralysis (VCP) from March 1998 to March 2020. […] The most common etiology for UVCP was idiopathic, and for BVCP was thyroid and parathyroid surgery. For both, UVCP and BVCP there was increasing trend for surgical and decreasing trend for non-surgical etiology. The change in voice was the most common presenting complain, with decrease in duration of symptom onset over time period. […] The VCP results primarily due to the neurological or the mechanical cause. […] There have been multiple studies suggesting various etiological factors responsible for VCP, often without proper agreement on the most common etiology. […] The present study evaluates the etiology and presenting features of the UVCP and BVCP patients over the 22 years at a single institute.

• #19 Etiology and presenting features of vocal cord paralysis: changing trends over the last two decades | The Egyptian Journal of Otolaryngology | Full Text

  https://ejo.springeropen.com/articles/10.1186/s43163-022-00322-x

  The patients of VCP were routinely investigated using various imaging modalities such as CT scan, MRI and MBS in order to find out the etiology behind the VCP. […] The total number of non-surgical etiology were decreased, as shown by our study, in second group when compared to the first group for both UVCP and BVCP. […] The present study was the largest study found in the literature that has shown the changing trend of etiology and presenting features of UVCP and BVCP, over the time duration of 22 years.

• #20 Vocal Fold Paralysis (Vocal Cord Paralysis) Etiologies | Iowa Head and Neck Protocols

  https://medicine.uiowa.edu/iowaprotocols/vocal-fold-paralysis-vocal-cord-paralysis-etiologies

  Between 118,000 and 166,000 patients in the United States undergo thyroidectomy per year for benign or malignant disease (Chandrasekhar 2013) […] Review article identifies vocal cord paralysis to be a significant morbidity after anterior cervical spine surgery with incidence up to 24.2% in the immediate postoperative period.

• #21 COVID-19 Infection Causes Teen’s Vocal Cord Paralysis in First-Of-Its-Kind Case

  https://masseyeandear.org/news/press-releases/2023/12/covid-19-infection-causes-teens-vocal-cord-paralysis

  The case highlights the importance of considering COVID-19 infection as a possible cause of vocal cord paralysis in children. […] Physician-researchers from Mass Eye and Ear, a member of Mass General Brigham, report the first pediatric case of bilateral vocal cord paralysis after COVID-19 (SARS-CoV-2) infection. […] The researchers concluded that this paralysis was likely a downstream effect of the COVID-19 virus when an extensive workup revealed no other cause. […] The case, which is presented December 19th in the journal Pediatrics, suggests that vocal cord paralysis may be a nervous system-related (neuropathic) complication of the virus, in addition to already well-established neurologic complications in children and adults. […] Given how common this virus is among children, this newly recognized potential complication should be considered in any child presenting with a breathing, talking or swallowing complaint after a recent COVID-19 diagnosis.

• #22 COVID-19 Infection Causes Teen’s Vocal Cord Paralysis in First-Of-Its-Kind Case

  https://masseyeandear.org/news/press-releases/2023/12/covid-19-infection-causes-teens-vocal-cord-paralysis

  Post-viral neuropathy is a known cause of vocal cord paralysis, and there have been several reports of paralysis in one or both vocal cords of adults as a complication of SARS-CoV-2 infection, but this is the first report of the complication in an adolescent. […] The fact that kids can actually have long term neurotrophic effects from COVID-19 is something that it’s important for the broader pediatric community to be aware of in order to be able to treat our kids well.

• #23 Bilateral vocal cords paralysis requiring urgent tracheostomy on COVID-19 patient: a case report | JA Clinical Reports | Full Text

  https://jaclinicalreports.springeropen.com/articles/10.1186/s40981-022-00578-5

  A COVID-19 patient who underwent injurious ventilation developed vocal cord paralysis and edema 6 days after extubation, leading to an emergency tracheostomy. […] We report a patient with severe COVID-19 who required an emergency tracheostomy due to bilateral vocal cord paralysis a week after extubation. […] The frequency of paralysis is about 0.1% in patients who undergo tracheal intubation for surgery, and most are unilateral. […] Among the episodes of thousands of and millions of COVID-19 patients around the globe, there are several reports on vocal cord paralysis. […] However, bilateral vocal cord paralysis and the fact that the symptoms and signs of airway obstruction became evident a few days after the extubation does not suggest that mechanical damage to vocal cords or recurrent nerves during intubation was the cause of the paralysis. […] Although the exact mechanism is unclear, there exists vocal cords palsy and edema in COVID-19 patients long after the extubation or even without a history of tracheal intubation.

• #24 Vocal cord paresis – Wikipedia

  https://en.wikipedia.org/wiki/Vocal_cord_paresis

  Due to the complex and controversial nature of this condition, epidemiological (incidence) reports vary significantly and more research in this area is needed. […] In such a setting, one study found that approximately 26% of patients are diagnosed with paralysis or paresis of the vocal folds. […] Yet, incidence rates as high as 80% for vocal fold paresis have been reported elsewhere. […] Yet another source reported only 71 cases of vocal fold paresis over 7 years. […] Incidence rates of vocal fold paresis after undergoing thyroid surgery have been reported between 0.3% and 13.2%, whereas these incidence rates are between 2% and 21.6% after undergoing spinal surgery.

• #25 Top Published Expert Doctors for Vocal Cord Paralysis

  https://findexpertmd.com/d/Vocal_Cord_Paralysis

  736 top medical experts on Vocal Cord Paralysis across 45 countries and 37 U.S. states, including 674 MDs (Physicians). This is based on an objective analysis of their Scientific Publications, Clinical Trials, Medicare, and NIH Grants. […] Vocal Cord Paralysis: Congenital or acquired paralysis of one or both vocal cords. This condition is caused by defects in the central nervous system, the vagus nerve and branches of laryngeal nerves. Common symptoms are voice disorders including hoarseness or aphonia. […] Clinical Trials: at least 41 including 1 Active, 22 Completed, 7 Recruiting.

• #26 Vocal Cord Paralysis | Condition | UT Southwestern Medical Center

  https://utswmed.org/conditions-treatments/vocal-cord-paralysis/

  The Voice Center at UT Southwestern Medical Center offers exceptional expertise in diagnosing and treating vocal cord paralysis and other voice disorders. […] Our team members are widely recognized as experts in the accurate diagnosis and effective treatment of vocal cord paralysis. […] Through our research, we have made important contributions to the standard of care and are improving the lives of patients, here and across the country.

• #27 Vocal Cord Paralysis: Understanding and Managing

  https://www.nuffieldent.com.sg/vocal-cord-paralysis/

  Vocal Cord Paralysis, also known as vocal fold paralysis, is a medical condition characterized by the partial or complete loss of movement in one or both vocal cords. These cords, situated in the larynx (voice box), play a crucial role in producing sound during speech and breathing. Vocal cord paralysis can significantly impact voice quality, breathing, and overall quality of life. […] Vocal cord paralysis is relatively uncommon but can affect individuals of all ages. Its prevalence varies depending on the underlying causes and risk factors. Timely diagnosis and appropriate treatment are crucial for managing this condition effectively. […] After surgical or non-surgical treatment for vocal cord paralysis, regular evaluations and follow-up appointments are crucial. This allows the ENT specialist to assess the effectiveness of treatment, make necessary adjustments, and monitor the patients progress in voice quality and breathing. […] Vocal cord paralysis can significantly impact an individuals ability to speak and breathe comfortably. Seeking prompt evaluation and treatment by an ENT specialist is essential to address this condition effectively and improve overall quality of life.

• #28 Vocal Cord Dysfunction: Practice Essentials, Background, Pathophysiology

  https://emedicine.medscape.com/article/137782-overview

  Vocal cord dysfunction (VCD) is observed in up to 10% of patients at referral centers seeking evaluation of asthma that is unresponsive to aggressive therapy. The literature reveals a high incidence of VCD in persons with psychiatric conditions (eg, depression, obsessive-compulsive disorder, borderline personality disorder, neuroses induced by childhood sexual abuse) […] VCD may complicate true asthma in a small number of patients. […] Mortality rates are unknown, but morbidity is often significant from years of corticosteroid use, resulting in iatrogenic Cushing-like syndrome, bone density loss, and growth suppression in the pediatric population. Misdiagnosis of VCD as asthma may lead to significant morbidity and increased costs, and misuse of measures of asthma control may be contributing to these findings.

• #29 Vocal Fold Paralysis and Vocal Fold Paresis | Atrium Health Wake Forest Baptist

  https://www.wakehealth.edu/condition/v/vocal-fold-paralysis-and-paresis

  Your laryngologist may also recommend an imaging study (such as a CT of the chest and neck) to help in determining the cause of your voice disorder. […] In cases of vocal fold paresis and paralysis which do not respond to voice therapy, surgical intervention is offered. Surgery options primarily consist of medialization procedures that attempt to push the affected vocal fold to a more favorable position (ie in the middle of the body). […] These procedures often significantly improve the voice, and in some cases, voice therapy may also be recommended post-operatively.

• #30 Bulking Agents for the Treatment of Vocal Cord Paralysis

  https://www.southcarolinablues.com/web/public/brands/medicalpolicy/external-policies/bulking-agents-for-the-treatment-of-vocal-cord-paralysis/

  In a multi-institutional retrospective review, Sulica et al. (2010) identified contemporary indications, treatment principles, technique, injection materials, complications and success rates of vocal fold injection augmentation. […] The authors concluded that injection augmentation remains a safe, effective and clinically practical treatment with a high rate of success, whether performed in the awake or asleep patient. […] In a Cochrane review, Lakhani et al. (2012) evaluated the effectiveness of alternative injection materials in the treatment of UVFP. […] The authors concluded that there is currently insufficient high-quality evidence for or against specific injectable materials for patients with UVFP.

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