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Office Vocal Cord Injections: Applying bioengineered products to classic laryngologic problems Matthew Lutch, MD Head and Neck Surgery Kaiser Permanente.

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Presentation on theme: "Office Vocal Cord Injections: Applying bioengineered products to classic laryngologic problems Matthew Lutch, MD Head and Neck Surgery Kaiser Permanente."— Presentation transcript:

1 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

2 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)

3 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

4 Classics in VFI Brünings, 1911 –paraffin Arnold, 1963 –Teflon All initially office-based –Awake, upright patients

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

6 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: –Scalco, et al. Microscopic suspension laryngoscopy. Ann Otol Rhinol Laryngol. 1960;69:

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

8 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

9 Disadvantages of VFI Preprocedure anxiety Intraprocedural gagging Cannot guarantee longevity of implant Precision of injection α patient comfort

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

11 Why hyaluronic acid? The goo molecule Carbohydrate polymer Extracellular matrix (15 grams/70 kg) Natural lubricant (synovial fluid) Cross-linking increases longevity

12 NO COMMERCIAL DISCLOSURES

13 Juvederm Ultra series 34 patients 4 required repeat injection x 1 1 required repeat injection x 2 5 bilateral injectees 45 total injections

14 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

15 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

16 Technique of transoral injection Base of tongue directly topicalized –Cetacaine –Methemoglobinemia Atomized 4% lidocaine treatment Direct glottic topicalization

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19 Video: Topical Being Dripped Directly into glottis

20 Case #1 55 year old man s/p open resection of chondrosarcoma Substantial glottic insuffiency secondary to loss of paraglottic tissue and RLN sacrifice

21 Preinjection stroboscopy film 1A Injection film 1B Postinjection (6m) stroboscopy 1C

22 Case #2 79 year-old with dysphonia after left carotid endarterectomy Left vocal fold paralysis and left sulcus vocalis deformity Injection addresses both

23 RW2A – preinjection strobe RW2B – injection/multiple passes RW2C – postinjection strobe

24 Case #3 70 year old jewelry salesman Breathy dysphonia s/p CABG Intubated with 8.5 endotracheal tube

25 JHpresby3A: preinjection strobe JHpresby3B: bilateral vfi JHpresby3C: postinjection strobe

26 Followup 1 to 17 months 5 patients required repeat injection 1 underwent open thyroplasty

27 Summary Rejuvenating time-honored approaches More options for patients Decreased downtime Minimal risk Followup driven by patients:


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