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Laryngology Seminar
Injection laryngoplasty for unilateral vocal fold paralysis
R3 黃俊棋 2005/08/31
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Introduction:
Causes of unilateral vocal fold paralysis:
 Stretch or transaction of vagus nerve during neck or chest surgery
 Blunt trauma to neck or chest
 Nerve compression by neck or chest tumor
 Viral infection
 Idiopathic
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Treatment options:
 Wait spontaneous improvement
 Voice therapy (first choice before any surgical procedure)
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Factors influence treatment:
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Degree of dysphonia
Patient motivation for symptom improvement
General healthy condition
Probability of recurrent laryngeal nerve recovery
Shape of glottal defect
Injection laryngoplasty:
Indication:
 Unilateral laryngeal paralysis
 Chordectomy or hemilaryngectomy
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Injection laryngoplasty
Laryngeal framework surgery (thyroplasty type I with or without arytenoids
adduction still gold standard)
Reinnervation surgery (nerve-nerve anastomosis or nerve-muscle implant)
Congenital vocal cord deficiency
Acquired vocal cord defect
Contraindication:
 Before voice therapy
 Within 6 months since onset of laryngeal paralysis
 Psychogenic or emotional disorder
 Bilateral laryngeal paralysis
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Lesion of central nerve system
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Large interarytenoid gap
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Technique:
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Injection substances:
Classification:
 Xenograft: bovine collagen, hyaluronic acid
 Homograft: cymetra
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Autograft: autologous fat, fascia, collagen
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Synthetic: paraffin, Teflon, silicone, calcium hydroxylapatite, gelfoam
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Ideal materials:
 Biocompatible
 Easily injection through a small needle
 Readily available with minimal preparation
 Same or similar biomechanical properties to vocal fold component
 Resistant to resorption or migration
 Easily removal
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Paraffin: (Bruening W, 1911)
 First injection laryngoplasty with Bruening syringe
 Foreign body reaction; extrusion; migration; inflammation
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Autologous cartilage and bone dust: (Arnold GE, 1950s)
 Little inflammatory reaction but quick absorption
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Teflon (polytetrafluorethylene): (Arnold GE, 1962)
 Ease of preparation and injection
 Most ideal material till 1990s
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Migration of particles; giant cell foreign body reaction; granuloma formation;
difficult to remove; hard, nonvibrating vocal cord; scaring
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Particular silicone (pokydimethylsiloxane):
 Stable medialization of vocal fold
 Same foreign body giant cell reaction as Teflon
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Bovine collagen (purified, enzyme-digested collagen):
 1-2% delayed type hypersensitivity and require skin test
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Variable resorption rate
FDA not approve for intralaryngeal use
Autologous collagen:
 no hypersensitivity reaction
 Variable resorption rate, though lower than bovine collagen
 Donor site morbidity
 45 days processing time
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Autologous fat:
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no hypersensitivity reaction
similar biomechanical properties to vocal fold component
Shindo et al. 1996, 21 cases:
excellent result within 2 months but remarkable fat loss after 3 months
Donor site morbidity
Decrease damage of adipocyte to prevent fatty acid, triglyceride release
Variable resorption rate (20-90%), 30-40% over injection
Preadipocyte: lower survival rate than lipoinjection after 6 and 12 months
Autologous fascia (fascia lata):
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no hypersensitivity reaction
Rihkanen H. 1998, 9 cases:
Improve voice quality and MPT without deterioration within 10 months F/U
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Another 14 cases with 13 months F/U:
Excellent result without hampered mucosal wave, scar or fibrosis
Donor site morbidity and need large syringe
Absorption?
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Gelfoam (bioabsorbable gelatin material):
 Temporary use and resorption within 4-12 weeks
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Cymetra:
 Acellular cadaveric dermal tissue without alteration of collagen and elastin
matrix
 no hypersensitivity reaction till now and no donor site morbidity
 excellent result within 1 month but about 30% absorption within 3 months
 Lundy et al. 2003, 8 cases:
Improvement in jitter, N/H, airflow, VHI same as type I thyroplasty within 1
month
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FDA not approve for intralaryngeal use
Calcium hydroxylapatite:
 Basic component of bone and teeth and injection along with gel
 No antigenic and inflammory response
 Can be removed easily within 6 weeks
 FDA approve for intralaryngeal use
 Rosen et al. 2004, 11 cases:
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Improvement in VHI and mean airflow within 6 months
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10-15% over injection because of resorption of gel
Mucosal wave?
Hyaluronic acid:
 Polysaccharide, Hylan b gel and Restylane
 similar biomechanical properties to vocal fold component
 Hertegard et al. 2002, 83 cases, F/U 12 months
Same result as bovine collagen but less resorption and great MPT increase
 Hylan b gel: from rooster combs, though no species-specific antigen, not
recommend for avian product allergy patient
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Restylane: microbiologic engineering techniques, 3 case report of
granulomatous foreign body reaction
Resorption?
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Conclusion:
thyroplasty type I with or without arytenoids adduction still gold standard
make sure of effect of thyroplasty before surgery
terminal patient
cosmetic consideration
5.
Reference:
 Arnold GE: Vocal rehabilitation of paralytic dysphonia IX. Technique of
intrachordal injection. Arch Otolaryngol 1962, 76:358-368.
 Arnold GE: Vocal rehabilitation of paralytic dysphonia: cartilage injection into a
paralyzed vocal coed. Arch Otolaryngol 1955, 62:1-17.
 Rubin HJ: Pitfalls in treatment of dysphonia by intrachordal injection of
synthetics. Laryngoscope 1965, 75:1381-1397.
 Homicz MR, Watson D: Review of injectable materials for soft tissue
augmentation. Facial Plast Surg 2004, 1:21-29.
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Pearl AW et al. A preliminary report on micronized alloderm injection
laryngoplasty. Laryngoscope 2002, 112:990-996.
Karpenko AN et al. Cymetra injection for unilateral vocal fold paralysis. Ann
Otol Rhinol Laryngol 2003, 112:927-934.
Lundy DS et al. Early results of transcutaneous injection laryngoplasty with
micronized acellular dermis versus type-I thyroplasty for glottic incompetence
dysphonia due to unilateral vocal fold paralysis. J Voice 2003, 17:589-595.
Zaretsky LS et al. Autologous fat injection for unilateral vocal fold paralysis.
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Ann Otol Rhinol Laryngol 1996, 105:602-606.
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Glatz FR et al. Volume analysis of preadipocyte injection for vocal cord
medialization. Laryngoscope 2003, 113:1113-1117.
Rihkanen H: Vocal fold augmentation by injection of autologous fascia.
Laryngoscope 1998, 108:51-54.
Rihkanen H et al. Videostroboscopic assessment of unilateral vocal fold
paralysis after augmentation with autologous fascia. Eur Arch Otorhinolaryngol
2004, 261:177-183.
Rosen CA et al. Vocal fold augmentation with injectable calcium
hydroxylapatite: Short-term result. J Voice 2004, 18(3):387-391.
Fernandez MJ et al. Granulomatous foreign body reaction against hyaluronic
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acid: Report of a case after lip augmentation. Dermatol Surg 2003,
29:1225-1226.
Caballero M et al. Particulate silicone for vocal fold augmentation: Morpho,etric
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evaluation in a rabbit model. Ann Otol Rhinol Laryngol 2004, 113:234-241.
Kwon TK, Buckmire R: Injection laryngoplasty for management of unilateral
vocal fold paralysis. Curr Opin Otolaryngol Head Neck Surg 2004, 12:538-542.