Office Vocal Cord Injections:
Applying bioengineered products to
classic laryngologic problems
Matthew Lutch, MD
Head and Neck Surgery
Kaiser 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
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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?
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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
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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…
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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 1A
Injection film 1B
Postinjection (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 strobe
RW2B – injection/multiple passes
RW2C – postinjection strobe
Case #3
• 70 year old jewelry salesman
• Breathy dysphonia s/p CABG
• Intubated with 8.5 endotracheal tube
JHpresby3A: preinjection strobe
JHpresby3B: bilateral vfi
JHpresby3C: postinjection strobe
Followup
• 1 to 17 months
• 5 patients required repeat injection
• 1 underwent open thyroplasty
Summary
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Rejuvenating time-honored approaches
More options for patients
Decreased downtime
Minimal risk
Followup driven by patients: