1. Kaiser Permanente Medical Center
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 Arnold, 1963
paraffin
Arnold, 1963
Teflon
All initially “office-based”
Awake, upright patients

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

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
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

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: