Early Injection Laryngoplasty Research Articles

Augmentation and vocal fold biomechanics in a recurrent laryngeal nerve injury model.

Objectives/hypothesisComposite vocal fold (VF) biomechanical data are lacking for augmentation after recurrent laryngeal nerve (RLN) injury. We hypothesize resulting atrophy decreases VF stiffness and augmentation restores native VF biomechanics.MethodsSixteen Yorkshire Crossbreed swine underwent left RLN transection and were observed or underwent carboxymethylcellulose (CMC) or calcium hydroxyapatite (CaHa) augmentation at 2 weeks. Biomechanical measurements (structural stiffness, displacement, and maximum load) were measured at 4 or 12 weeks. Thyroarytenoid (TA) muscle cross‐sectional area was quantified and compared with two‐way ANOVA with Tukey's post hoc test.ResultsAfter 4 weeks, right greater than left structural stiffness (mean ± SE) was observed (49.6 ± 0.003 vs. 28.4 ± 0.002 mN/mm), left greater than right displacement at 6.3 mN (0.54 ± 0.01 vs. 0.46 ± 0.01 mm, p < .01) was identified, and right greater than left maximum load (72.3 ± 0.005 vs. 40.8 ± 0.003 mN) was recorded. TA muscle atrophy in the injured group without augmentations was significant compared to the noninjured side, and muscle atrophy was seen at overall muscle area and individual muscle bundles. CMC augmentation appears to maintain TA muscle structure in the first 4 weeks with atrophy present at 12 weeks.ConclusionsVF biomechanical properties match TA muscle atrophy in this model, and both CMC and CaHa injection demonstrated improved biomechanical properties and slower TA atrophy compared to the uninjured side. Taken together, these data provide a quantifiable biomechanical basis for early injection laryngoplasty to improve dysphonia and potentially improve healing in reversible unilateral vocal fold atrophy.Level of evidenceN/A

Long-Lasting Effect after Single Hyaluronate Injection for Unilateral Vocal Fold Paralysis: Does Concentration Matter?

Background: Early injection laryngoplasty (EIL) using hyaluronic acid (HA) is an effective treatment for glottic insufficiency in patients with acute unilateral vocal fold paralysis (UVFP). Most patients benefit by showing improvement in voice and quality of life and implied reduced need for permanent laryngoplasty. However, injected HA might resolve within a short period, so its long-term outcomes and the need for secondary procedures need to be clarified. Methods: Patients who underwent EIL with HA for acute UVFP from January 2015 to December 2018 were included. The factors that may associate with the prognosis including voice performance and laryngeal configuration at presentation, the cause of UVFP, and the type of HA for EIL were analyzed. Results: Ninety-four patients were included for analysis, with a mean follow-up period of 25.1 months (95% CI: 22.8–27.4 months). After primary HA injection, 22 patients (23.4%) underwent secondary procedures (rate: 13.1% per person-year), and most (63.6%) of the events occurred after one year from the first injection. The rate of secondary procedures within the first 12 months was 9.0% (14.1% and 4.3% for low-concentrated HA (LHA) and high-concentrated HA (HHA), respectively). The incidence of the secondary procedures was higher in the LHA group (18.2%) (p = 0.026) than in the HHA group (7.5%). Conclusions: The rate of secondary procedures was lower than the prediction based on the resorption time of HA, a finding that could be partly accounted for by both natural nerve recovery and a long-lasting effect of EIL. EIL with HHA had a lower rate of re-treatment than that with LHA, suggesting a better clinical utility for acute UVFP.

Effects of percutaneous injection laryngoplasty on voice and swallowing problems in cancer-related unilateral vocal cord paralysis.

BackgroundUnilateral vocal cord paralysis may result from nerve compression by tumors or direct nerve injuries during tumor resections, which can cause dysphonia or dysphagia, and reduced quality of life.ObjectivesThis prospective, single‐group study aimed to investigate the effect of percutaneous injection laryngoplasty on voice and swallowing function in patients with cancer‐related unilateral vocal cord paralysis.MethodsPatients underwent percutaneous injection laryngoplasty with hyaluronic acid under local anesthesia. Stroboscopy and videofluoroscopic swallowing study were conducted to evaluate the voice‐ and swallowing‐related outcome measures, respectively. The participants were evaluated before injection laryngoplasty, as well as after two weeks and three months.ResultsInjection laryngoplasty significantly improved the glottal gap, vocal fold position, Maximum Phonation Time, and Voice Handicap Index‐10. Post‐hoc analysis using Bonferroni correction showed that the improvements occurred within two post‐treatment weeks and remained at three post‐treatment months. In the subgroup analysis, the patients who underwent injection laryngoplasty within 8 weeks from onset showed significantly higher improvements in the videofluoroscopic dysphagia scale and swallowing function than the patients who received the procedure after 8 weeks or more.ConclusionPercutaneous injection laryngoplasty improves glottal closure and voice in patients with cancer‐related unilateral vocal cord paralysis. Early injection laryngoplasty may lead to greater benefits on swallowing function.Level of Evidence4.

Outcomes of Esophageal Cancer after Esophagectomy in the Era of Early Injection Laryngoplasty.

(1) Background: severe weight loss was reported to be related to unilateral vocal fold paralysis (UVFP) after esophagectomy and could thus impair survival. Concomitant radical lymph node dissection along the recurrent laryngeal nerve during esophageal cancer surgery is controversial, as it might induce UVFP. Early intervention for esophagectomy-related UVFP by administering intracordal injections of temporal agents has recently become popular. This study investigated the survival outcomes of esophagectomy for esophageal squamous cell carcinoma (ESCC) after the introduction of early injection laryngoplasty (EIL). (2) Methods: a retrospective review of patients with ESCC after curative-intent esophagectomy was conducted in a tertiary referral medical center. The necessity of EIL with hyaluronic acid was comprehensively discussed for all symptomatic UVFP patients. The survival outcomes and related risk factors of ESCC were evaluated. (3) Results: among the cohort of 358 consecutive patients who underwent esophagectomy for ESCC, 42 (11.7%) showed postsurgical UVFP. Twenty-nine of them received office-based EIL. After EIL, the glottal gap area, maximum phonation time and voice outcome survey showed significant improvement at one, three and six months measurements. The number of lymph nodes in the resected specimen was higher in those with UVFP than in those without UVFP (30.1 ± 15.7 vs. 24.6 ± 12.7, p = 0.011). The Kaplan–Meier overall survival was significantly better in patients who had UVFP (p = 0.014), received neck anastomosis (p = 0.004), underwent endoscopic resection (p < 0.001) and had early-stage cancer (p < 0.001). Multivariate Cox logistic regression analysis showed two independent predictors of OS, showing that the primary stage and anastomosis type are the two independent predictors of OS. (4) Conclusion: EIL is effective in improving UVFP-related symptoms, thus providing compensatory and palliative measures to ensure the patient’s postsurgical quality of life. The emerging use of EIL might encourage cancer surgeons to radically dissect lymph nodes along the recurrent laryngeal nerve, thus changing the survival trend.

Effectiveness of Injection Laryngoplasty for Aspiration in Acute Iatrogenic Vocal Fold Paralysis: A Systematic Review.

To review current evidence on effectiveness of injection laryngoplasty on aspiration outcomes in acute unilateral vocal fold paralysis. Systematic review. A literature search was performed on MEDLINE, Embase, Scopus, and the Cochrane Library from inception of each database to May 2019. Inclusion criteria included case series, case-control studies, prospective cohort studies, and randomized controlled trials assessing the outcomes of early injection laryngoplasty on aspiration in unilateral vocal fold paralysis, in the acute setting. Only English articles with adult study populations were included. Two independent investigators screened all abstracts and manuscripts. Data on study design, patient demographics, interventions, and outcome measures were systematically extracted by both authors for included studies. Fourteen case series studies comprising 582 patients were included. Results were not quantitatively synthesized due to the heterogeneity of outcome measures. Eleven studies reported that a majority (ranging 50%-100%) of patients in each respective study showed improvement in diet intake (progression from nil per os to oral) or Penetration-Aspiration Scale (PAS) scores after injection laryngoplasty. However, none of the investigations used a control group, and therefore, did not account for the possibility of improvement of function related to placebo or Hawthorne effects rather than attributed to intervention. No robust evidence was found to support injection laryngoplasty as an effective measure to improve aspiration outcomes in acute iatrogenic vocal fold paralysis. Current practices rely on empirical observations and scarce expert opinions. Further prospective investigations with controlled objective measures are necessary to definitively demonstrate the effectiveness of IL for aspiration management. Laryngoscope, 132:813-821, 2022.

Early Injection Laryngoplasty With a Long-Lasting Material in Patients With Potentially Recoverable Unilateral Vocal Fold Paralysis.

Objectives.Injection laryngoplasty (IL) is one of the major options for treatment of unilateral vocal fold paralysis (UVFP). Early IL in patients with abrupt-onset UVFP can reduce hoarseness and aspiration-related discomfort and complications. Temporary or short-lasting materials are recommended for the early IL since permanent or long-lasting materials may negatively affect the voice quality when vocal fold motion is spontaneously recovered.Methods.Patients who received IL with a long-lasting material (ArteSense) within 1 month following development of postoperative UVFP were enrolled for this study. They were categorized into a spontaneously recovered group (n=30) and unrecovered group (n=276) from UVFP. The subjective and objective voice parameters were collected before and 6 months after IL. Patients’ demographics and collected voice parameters were compared between the two groups.Results.Age and sex distributions were not different between the two groups. Aspiration symptom, maximum phonation time (MPT), jitter, shimmer, noise to harmonic ratio (NHR), overall grade (G) and breathiness (B) of GRBAS (grade of dysphonia, roughness, breathiness, asthenia, strain) scale score, and voice handicap index (VHI) were significantly improved after IL in both groups. The amounts of improvement in MPT, jitter, shimmer, NHR and VHI were significantly greater in the recovered group. There was no IL-related complication including granuloma formation, hypersensitivity to injection material, or worsening of hoarseness.Conclusion.Early IL with a long-lasting material can be safely performed to improve voice quality and to reduce aspiration episode for the patients with postoperative UVFP, regardless of recovery from the paralysis. The amounts of improvement in the subjective and objective voice parameters were significantly greater in patients who showed spontaneous recovery from UVFP when compared with those in patients who did not.

Management of Vocal Fold Paralysis and Dysphagia for Neurologic Malignancies in Children.

To evaluate our experience with a significant number of brain malignancy-related vocal fold paralysis patients and their response to vocal cord-related therapies. Vocal fold paralysis is a potentially devastating complication of various types of pediatric diseases and surgeries that can lead to significant vocal and swallowing difficulties. While there is significant data in the literature on outcomes of children treated for vocal fold paralysis following cardiac or thyroid surgery, there is a scarcity of such information on children following the treatment of neurologic malignancy. Records of 19 patients at a tertiary center who were treated for neurologic malignancies and developed either unilateral or bilateral vocal fold paralysis were reviewed for vocal fold pathology and vocal fold paralysis treatment-related variables, including initial diagnosis, management with observation or speech therapy, duration of therapy, pre- and postintervention swallow studies, and surgical intervention. Bilateral vocal fold paralysis was noted in 26% (5/19) patients. Eighty-four percent (16/19) of patients had stable or improved ability to vocalize and swallow following therapy. There was no statistically significant difference in speech or swallowing improvement after speech therapy alone or speech therapy in combination with injection laryngoplasty (P = .25). No complications were noted with surgical intervention. Patients with vocal fold paralysis secondary to neurologic malignancy can have an improvement in speech and swallowing after a variety of treatments, including speech therapy or early injection laryngoplasty. There was no statistically significant difference in improvement based on the type of intervention utilized. A larger sample size is needed to conclude whether surgical intervention combined with speech therapy leads to more rapid and significant functional improvement than speech therapy alone.

Safety and efficacy of Early injection laryngoplasty in pediatric patients.

The major morbidity of unilateral vocal fold immobility (UVFI) in children is due to aspiration. Early injection laryngoplasty (IL) can decrease aspiration risk; however, this has not been well studied in pediatric otolaryngology. This study examines safety and efficacy of early IL in children. Retrospective review of pediatric patients undergoing IL with any injectate between 2006 and 2017 within 6 months of onset of UVFI. Outcomes included diet pre- and postprocedure, incidence of aspiration-related sequelae, and adverse events. Seventeen patients met eligibility criteria. Ten (58.8%) were males. Median age was 8 months (interquartile range, 2 months-11.5 years). All patients had prior surgeries; the largest subgroup (11 patients, 64.7%) had UVFI after repair of a congenital cardiac defect. Other causes included thyroidectomy, high vagal injury, and prolonged intubation. Sixteen patients underwent swallowing evaluation prior to IL and 14 patients required dietary modifications due to aspiration risk. Consistency and/or volume of oral intake improved after IL in 10 (71.4%) of them. Five patients underwent gastrostomy tube placement for significant oromotor incoordination. Children with congenital cardiac defects had more previous surgeries (3.0 ± 0.4 vs. 1.2 ± 0.2, P = .006) and were more likely to require G-tube placement due to poor feeding despite IL (45% vs. 0%, P = .05). No patients experienced adverse events due to IL; in particular, none experienced airway symptoms requiring intubation. Early IL in pediatric patients with UVFI is safe and can reduce aspiration and improve oral intake. Future studies should elucidate patient subgroups most likely to benefit from this intervention. 4 Laryngoscope, 129:1699-1705, 2019.

Early Injection Laryngoplasty After Surgery: 30 Cases and Proposed Aspiration Assessment Protocol

Vocal fold movement impairment may significantly compromise postoperative recovery and quality of life of patients following thoracic or cardiothoracic surgery or prolonged intubation. The literature is limited and there is no standard screening protocol for the optimal postoperative swallowing and aspiration evaluations. We performed retrospective review of adult patients undergoing early vocal fold (VF) injection laryngoplasty for acute postoperative Vocal fold movement impairment (<30 days) that had both pre- and postinjection speech language pathologist (SLP) performed swallowing/aspiration evaluations. Records were reviewed for demographics, clinical characteristics, procedural details, and short-term outcome measures of oral intake. In total, 30 patients were included, and had data on swallowing/aspiration studies before and after the VF injection laryngoplasty. Most of the patients were injected within 5 days following the laryngologist evaluation and within 14 days following the iatrogenic recurrent laryngeal nerve injury (23/30, 76.7%). The majority of patients were injected at the bedside by awake transcutaneous injection (22/30, 73.3%), six patients were injected in the operating room under general anesthesia, and two at the outpatient clinic. Pre- and postinjection SLP evaluations included clinical bedside assessment or instrumental evaluation. Following VF injection laryngoplasty, oral diet advancement was noted in 81.8% of the patients that were nil per os before the injection (18/22). No complications were noted. In conclusions, acute VFMI following surgery requires immediate diagnosis and therapeutic strategy to minimize postoperative complications and to overcome impairments in the voice, swallow, and cough. Otolaryngology-SLP interdisciplinary aspiration and swallowing assessment protocol is proposed based on our experience and an extensive literature review.

Short term management of vocal fold paralysis

Vocal cord paralysis is commonly encountered by ENT surgeons. The standard management usually involves waiting for 6-12 months to assess for recovery or reinnervation. During this time, the patient usually experiences poor quality voice, ineffective cough, and aspiration which may result in pneumonia. Management of these patients includes a search for the aetiology and often requires speech therapy. In addition to this, a reversible, office-based early injection laryngoplasty can minimize the patient morbidity of impaired vocal fold mobility while maximizing glottal function and improving phonatory quality. Methods: A retrospective study was conducted on consecutive patients with unilateral vocal cord paralysis. Voice handicap index, basic and aerodynamic/acoustic data were collected at the initial assessment and following intervention. Intervention consisted of an office-based, unsedated, paraglottic injection of hyaluronic acid to the effected side. All patients underwent videostroboscopy before, during and after office intervention and subjective assessment of these recordings was made. Patients also completed the voice related quality of life. Results: All 185 patients tolerated office-based injection well with no adverse events. All patients experienced an improvement in glottal competency and this was reflected in the aerodynamic and acoustic data.

Anticoagulation and antiplatelet therapy in awake transcervical injection laryngoplasty.

Vocal fold movement impairment (VFMI) due to neuronal injury occurs in 20% to 30% of surgeries in the region of the aortic arch. Early injection laryngoplasty can aid with postoperative pulmonary toilet in these high-risk cardiovascular patients. The purpose of this study is to determine whether continuing antiplatelet and anticoagulation therapy during awake transcervical injection laryngoplasty surgery is safe, and if there is any increase in bleeding complications in these patients. This is a retrospective review of patients undergoing awake injection laryngoplasty surgery for VFMI between 2013 and 2016 at a tertiary academic center specializing in aortic and mediastinal diseases. Records were reviewed for patients regarding baseline antiplatelet or anticoagulation therapy, and whether these medications were stopped or continued preoperatively. The primary outcome was bleeding complications. Of the 95 surgeries reviewed, 44 (46%) were performed for patients on antiplatelet therapy, and 71 (75%) for patients on anticoagulation therapy. None of the patients on antiplatelet therapy had their treatment discontinued. Of the patients on anticoagulation, 13 (16.4%) had their therapy held prior to surgery. There was no observed difference in bleeding complications between patients who were continued on antiplatelet or anticoagulation treatment versus those whose therapy was withheld. These results suggest that patients undergoing awake transcervical injection laryngoplasty for VFMI can be maintained on antiplatelet or anticoagulation therapy without increased risk of bleeding. Further larger studies are needed to confirm these findings. 4. Laryngoscope, 127:1850-1854, 2017.

Early voice rehabilitation with injection laryngoplasty in patients with unilateral vocal cord palsy after thyroidectomy.

Injection laryngoplasty is a safe and efficient procedure for the management of hoarseness resulting from unilateral vocal cord paralysis (VCP). However, proper timing and material of injection after the occurrence of VCP are still under discussion. This study aimed to evaluate the efficacy of early injection laryngoplasty with long-lasting soft tissue filler in patients with post-thyroidectomy unilateral VCP. We retrospectively reviewed the medical records of 59 consecutive patients who developed unilateral VCP after thyroidectomy and received ArteSense™ injection laryngoplasty. Objective and subjective voice outcomes were compared between early (within 3 months) and late (after 3 months) injection groups. The mean duration from thyroidectomy to injection laryngoplasty was 39.7 and 334.2 days in the early and late injection groups, respectively. All of the tested objective and subjective voice parameters were significantly improved in both the early and late groups. However, the amount of voice improvement was significantly larger in the early injection group, especially jitter% (P = 0.02) and shimmer% (P = 0.03) improvement. Four patients showed spontaneous recovery from VCP after early injection laryngoplasty; nevertheless, their voice outcomes were excellent and there was no significant discomfort or complication. Early voice rehabilitation with injection laryngoplasty is a safe and efficient treatment in the patients with post-thyroidectomy unilateral VCP.