Office Vocal Cord Injections: Applying bioengineered products to

classic laryngologic problemsMatthew Lutch, MD

Head and Neck SurgeryKaiser Permanente Medical Center

San Diego, California

Medialization Procedures

• Terminology often unclear– Open vs endoscopic– Office-based vs operating room– Thyroplasty vs laryngoplasty– Injectable implants vs permanent implants

• Implantable implants?

– Laryngoplasty is catch-all• Thyroplasty reserved for open procedures• Injection laryngoplasty (IL)/vocal fold injection (VFI)

Vocal Fold Injection

• Classic Laryngologic Problems– Glottic insufficiency catches all

• Vocal fold paralysis/paresis• Tissue loss (neoplasm/trauma)• Presbylarynx (subset)

– Loss of superficial lamina propria– Sulcus vocalis

Classics in VFI

• Brünings, 1911 – paraffin

• Arnold, 1963– Teflon

• All initially “office-based”– Awake, upright patients

Manuel Garcia: Observations on the human voice. Proc Royal Soc London. 1855;7:397-410

Technique

• Mirror guided surgery

• General anesthesia - Standard of care ~1960– Priest, et al. Direct laryngoscopy under general anesthesia.

Trans Am Acad Opthamol Otolaryngol. 1960;64:639-48.– Scalco, et al. Microscopic suspension laryngoscopy. Ann Otol

Rhinol Laryngol. 1960;69:1134-8.

From Dedo, HH, Surgery of the Larynx and Trachea, 1990.

What awake VFI offers

• Shorter “down-time”

• Decreased cost (RVUs!)

• “Real-time” feedback– Addresses specific anatomic problem– More customized therapy– Multiple bioengineered injectable options – Open thyroplasty - OR mandated

Disadvantages of VFI

• Preprocedure anxiety

• Intraprocedural gagging

• Cannot guarantee longevity of implant

• Precision of injection α patient comfort

Injectable options

• Duration, viscosity, inflammatory risk– Saline– Gelfoam– Restylane/Juvederm– Collagen– Fat– Artecoll/Teflon/Radiesse (CaHA)

Why hyaluronic acid?

• The “goo” molecule

• Carbohydrate polymer

• Extracellular matrix (15 grams/70 kg)

• Natural lubricant (synovial fluid)

• Cross-linking increases longevity

NO COMMERCIAL DISCLOSURES

Juvederm Ultra series

• 34 patients

• 4 required repeat injection x 1

• 1 required repeat injection x 2

• 5 bilateral injectees

• 45 total injections

Patient population

GLOTTIC INSUFFICIENCY CATCHES ALL…• Idiopathic -12• Lung cancer – 4• Thyroid cancer – 3 • Esophageal cancer 2• Metastatic breast - 2• Presbylarynx – 5• Chondrosarcoma – 1• Jugular foramen schwannoma – 1• Carotid endarterectomy – 3• Cricoarytenoid joint fixation - 1

Awake approaches

• Real time voice/visual feedback• Transoral*

– Duplicates approach of direct laryngoscopy– Difficult in the gagging patient

• Percutaneous– Transcricothyroid– Transthyrohyoid– Requires MD or SLP to drive scope– Optimal in gagging patient

Technique of transoral injection

• Base of tongue directly topicalized– Cetacaine– Methemoglobinemia

• Atomized 4% lidocaine treatment

• Direct glottic topicalization

Video: Topical Being Dripped Directly into glottis

Case #1

• 55 year old man s/p open resection of chondrosarcoma

• Substantial glottic insuffiency secondary to loss of paraglottic tissue and RLN sacrifice

Preinjection stroboscopy film 1AInjection film 1BPostinjection (6m) stroboscopy 1C

Case #2

• 79 year-old with dysphonia after left carotid endarterectomy

• Left vocal fold paralysis and left sulcus vocalis deformity

• Injection addresses both

RW2A – preinjection strobeRW2B – injection/multiple passesRW2C – postinjection strobe

Case #3

• 70 year old jewelry salesman

• Breathy dysphonia s/p CABG

• Intubated with 8.5 endotracheal tube

JHpresby3A: preinjection strobeJHpresby3B: bilateral vfiJHpresby3C: postinjection strobe

Followup

• 1 to 17 months

• 5 patients required repeat injection

• 1 underwent open thyroplasty

Summary

• Rejuvenating time-honored approaches

• More options for patients

• Decreased downtime

• Minimal risk

• Followup driven by patients: