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

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 Arnold, 1963 paraffin Arnold, 1963 Teflon All initially “office-based” Awake, upright patients

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

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

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

Why hyaluronic acid? 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 34 patients 4 required repeat injection x 1 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

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