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:
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 Preprocedure anxiety Intraprocedural gagging Cannot guarantee longevity of implant Precision of injection α patient comfort
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