Collagen Hydrogels for Vocal Fold Restoration

Vocal folds, often referred to as vocal cords, are composed of twin infoldings of mucous
membrane stretched horizontally across the larynx [as shown in Figure 1 (7)]. They vibrate,
modulating the flow of air being expelled from the lungs during phonation (1). Phonation is the
modification of the vocal folds for speech. During speech, the degree of tension and space of
each vocal fold is modified to create a slit like hole that creates resistance to the air flow and sets
up a series of laryngeal sound waves with various pitch and intensity (2). Males tend to have a
larynx that is 40% larger than the female larynx and this difference in size is called the laryngeal
prominence (also known as the Adams apple) (3). Vocal fold resonating frequency varies
through each stage of life for both males and females. Baby cries have a fundamental frequency
of around 500 HzChild speech ranges from 250-400 Hzadult females tend to speak at
around 200 Hz on averageand adult males around 125 Hz (3). Repairing vocal folds proves to
be challenging because there are three main considerations specific to the therapeutic response
of vocal folds which must be addressed when designing and evaluating gel-based injectables:
inflammatory response, ECM remodeling response, and biomechanical response (45).

Figure 1. Vocal Fold Orientation

With the constant abuse vocal cords endure, injury is likely to occur. Vocal fold
scarring, a specific vocal fold injury is accompanied by a marked decrease in voice quality and
control secondary to pathophysiological [functional changes associated with or resulting from
disease or injury (5)] changes of the vocal fold lamina propria [allows for ease of vibration
throughout vocal fold (51)] extracellular matrix (ECM) (4). Living tissue is not a solid mass of
tightly packed cells. Much of a tissues volume is made up of extracellular spaceThis void is
filled with a complex meshwork called the extracellular matrix [ECM]the extracellular matrix
largely determines how a tissue looks and functions. The extracellular matrix is made up of
proteoglycans, water, minerals, and fibrous proteins. A proteoglycan is composed of a protein
core surrounded by long chains of starch-like molecules called glycosaminoglycans (6). There
were two main hydrogels tested to aid in restoration, hyaluronic acid (HA) based hydrogels and
polyethylene glycol (PEG)-diacrylate based hydrogels/semi-IPNs, which were found to
approximate the viscoelastic mechanical properties of the native human vocal mucosai (vibratory

component) and the vocal ligament (strain component), respectively (46). Many researches
have conducted several experiments to determine the most effective way of repairing vocal fold
scarring.
Vocal fold scarring [shown in Figure 2 (24)] is a term that refers to fibrous tissue
replacing normal tissue and causes multiple layers of the vocal folds to be fixed together (18).
When the vocal folds are fixed together, they lose the ability to be able to vibrate independently.
Vocal fold scarring usually results from blunt laryngeal trauma or, more commonly, as the
result of surgical injury after excision or removal of vocal fold lesions (20). Vocal fold scars
prevent the mucosa [mucous membrane (23)] from vibrating freely as a result of being fixed to
underlying tissue (22). A vocal fold scar needs to be evaluated by stroboscopy. A stroboscopy is
a laryngoscopy [examination of throat, voice box (larynx), and vocal cords (19)] with
synchronized strobe light that provides a slow motion-like view of vocal fold vibration (mucosal
wave) (16). Treatment of vocal fold scars is one of the most difficult voice problems to treat
and depends on the cause of the scar and how long the scar has been present (21). Surgery for
mature scars is a hassle because of the difficulty in restoring the layers to normal separation.
Normal separation is imperative for normal phonation (17).

Figure 2. Stroboscopy image of scarred vocal fold

Past research and experiments on vocal fold scarring have revealed changes in the
organization and distribution of extracellular matrix components (ECM), such as dense and/or
disorganized type 1 collagen deposition decreased elastin and decorin, increased fibronection,
and occasional decreases in hyaluronic acid (HA)Given that these histological changes stiffen
the properties of the vocal fold, phenotypic changes of vocal fold fibroblasts and a correction of
the distribution of ECM components is needed to restore the vocal fold after scarring (8).
Fibronectin functions, not only, as an adhesion molecule by anchoring cells to collagen substrate,
but also to organize cellular interactions with the extracellular matrix by binding to different
components of the extracellular matrix (9). Many hydrogels have been researched to test the
ability of restoration.

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