Evaluation and Management of Vocal Cord Paralysis

Evaluation and
Management of Vocal Cord
Paralysis
Peak Woo MD FACS
Clinical Professor
Mount Sinai Medical Center
New York
American Academy of Otolaryngology Oct. 5, 2009
Evaluation and Management of
VCP
Selection of treatment
between:
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Injection laryngoplasty
Medialization
laryngoplasty
Arytenoid adduction
Re-innervation
Goal A: Improve Laryngeal
Competence
Consider all : 1996-2006
Arytenoid adduction: 430 cases
Bilateral Medialization and medialization
alone : 280 cases
Injection laryngoplasty: 136 fat, 312
dermis, 22 Hydroxyapatite
Re-innervation: 4
Management of Unilateral Vocal Fold
Paralysis
Yes
Potential for recovery?
Patient's functional level
No
Glottic Configuration
No disability
Aspiration
Beathiness
Midglottic gap
Large posterior gap
Different levels
Observation
Speech therapy
Gelfoam injection
Fat injection
Cymetra injection
Collagen injection
Thyroplasty
Teflon injection
Arytenoid adduction
(+/- thyroplasty)
PRO/CON Injection
PRO
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Non-Invasive
Simple
Variety of implants
Small amount of
injection possible
Con
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Permanent?
Implant reaction
Voice quality
Irreversible
One shot
Pro/Con AA/ML
Pro
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Permanent
Can change level and
arytenoid position
Revision is possible
Shaped implant more
adjustable
Con
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Difficult to do well
Complications are
~5%
Implant carving
Difficult to correct
minor defects
Adynamic
Pro/Con Re-innervation
Pro
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Dynamic neuro-motor
tone
Potential for abduction
and adduction when
multiple nerves are
used for abductor and
adductor reinnervation
Con
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Have to wait 6 mo
Inconsistent results
Donor nerve sacrifice
Difficult to do in neck
that has been violated
Analysis of defect
C. Jackson 1932
Selection of patients for Rx
Pre-operative videostroboscopy
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mid-cord gap unilateral
mid-cord gap bilateral
posterior gap
arytenoid rotation
preoperative phonatory function
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airflow
phonation time, functional assessment
Injection
laryngoplasty
Puzzle of Injection Laryngoplasty
Timing
Technique
Material
Indication
How
Evidence of glottis
incompetence
Glottal gap
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Mid-cord, incomplete, anterior/ posterior
Paresis
Strobe evidence
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Phase shift
Open phase predominates
Best Patient
In general: When to consider an
inject able
When the gap is small
When the vocal folds
are pliable
When there is need
for edge or vocal fold
augmentation.
When (in general) not to inject:
Teflon in the mobile
vocal fold
When both vocal folds
are scarred and stiff
When the gap is:
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Posterior
Big ie. Greater than 2
mm.
The “Ideal” material (Arnold)
(1) it must be well
tolerated by the a
tissues
(2) it must not be reabsorbed in time
(3) it must be finely
dispersed in a harmless
vehicle in order to be
injectable
Three Most Common 2009
Fat, fascia as auto grafts
Micronized Dermis (Alloderm) as allograft
Hydroxy-apatite (Radiesse)
Cellulose jel (radiesse lite, Voice jel,
Nouvielle)
Hyalouronic acid (Restylane)
Temporary and semi-permanent
Saline (6hr)
Gelfoam (4 wks)
Radiesse light (?)
Hyalouronic acid
(Restylane (4mo)
Zyplast (4mo)
Autologus Fat
(variable)
Autologus fascia
(variable)
Micronized Dermis
(variable)
Radiesse (?)
Permanent implants:
Hyaluronic acid
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Not permanent
Teflon : permanent.
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Teflon granuloma
Hydroxyaptite (Rosen et al.)
Factors contribution to variability
Volume of defect
Volume injected
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.4 to 1.8 cc
Method of preparation and harvest of injectable
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Fat implant vs. liposuction
Needle size, mixture
Patient factors
Natural course of disease
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Re-innervation, further atrophy, neurological
progression
Site of Injection for Vocal Cord
Medialization
Fat
Teflon
Micronized
dermis
Ca
Hydroxyapatite
Gelfoam
GELFOAMTM
Primary use - temporary paralysis
Resorption in 3 – 4 weeks
Autologus Fat Injection
Good patient
acceptance
Prepared by separate
procedure
Viable fat cells with
lipocytes
SOFT filler material
Variable absorption
Need for separate
incision and time
Donor morbidity
Over injection
mandatory
Re-injection possible
VOCAL CORD INJECTION AUTOLOGOUS FAT
Primarily for temporary
paralysis
Resorption rate variable
Lasts at least 2 months
Fat injection
Unilateral Vocal Fold Paralysis
AUTOLOGOUS FAT INJECTION
Trans oral injection of fat
VOCAL CORD INJECTION
Technique
Anterior cord
injection
Post-injection
Micronized Dermis: AlloDerm
(Cymetra)
FDA approved transplantable biomaterial
Processed acellular human dermis
Injectable form of sheet AlloDerm
Provides a scaffold for host tissue in-growth
No host vs. graft immune response
Minimal loss of volume over time
Pearl AW, Woo P, Ostrowski R, Mojica J, Mandell DL, Costantino P
A preliminary report on micronized AlloDerm injection laryngoplasty
Laryngoscope 112(6):990-996, June 2002.
Preparation
325 mg =1 cc or 2 cc
Mix with 1.4 to 1.8 cc of 1 % lidocaine = 2
cc injectable
Use 2 cc if you are doing transoral.
Mix in two 3 cc syringes
Be careful not to get a big plug.
Amount needed
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Temp injection .8 cc, Permanent = 1.5 to 2 cc.
Preparation of Alloderm
Endoscopic view of injection
sites
(Brandenburg, Laryngoscope, 1992)
Post hemi-laryngectomy
Hydroxyapatite
Inject able form of Bone cement
Histology in canines:
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little host tissue interaction, little absorption
no visco-elastic studies
FDA approved
Role for hard tissue substitute or soft
tissue?
Site of Vocal Cord Injection
Collagen
Teflon
Fat
Gelfoam
Dermis
Hydroxyapatite
Unilateral Vocal Cord Paralysis
VOCAL CORD INJECTION
TECHNIQUES
RadiesseTM
Collagen
CaH
A
Gel
Off the Shelf
Aumentation of FVC with
hydroxyapatite:
Lee B, Woo P: Use of Injectable Hydroxy apatite in the secondary setting to restore glottic competence
after partial laryngectomy with arytenoidectomy. Annals of Otology, Rhinology and Laryngology
113 (8): 618-622 August 2004
Current role of HA
Augment partial laryngectomy defects.
Augment glottic defects in patient with out
vibration considerations.
Correction of arytenoid defects.
Inject inter-arytenoid defects.
As a permanent implant as in-office
injection.
Cervical transcutaneous
Trans-cervical Injection
Landmarks
1% Lidocaine x 1 cc to thyroid cartilage
Needle 19 g needle 1 3/8 inch needle
Step down to the thyroid cartilage
Perpendicular to the thryoid cartilage
At crico-thyroid membrane go in 2 mm
Aim cephalad 40 degree by wiggling
forward slowly
Look for needle dimpling below the cord.
Trans-cervical Site of Injection Lateral View
Injection Trans-cervical :
Micronized Dermis
Office injection vs. Operative
Office
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High Patient
acceptance
Low morbidity
No need for reversal of
anti-coagulation
1.5 I/R
May be repeated
Risk of failure 10%
Less precision
Operative
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Precision
Need for operative
clearance
Massage the implant
is possible
Risks of anesthesia
Office injection: Bilateral
Complications
Removal of implant
Summary:
Injection laryngoplasty is good for small gaps or
those with good reversibility.
Temporary vs permanent augmentation
available. Gelfoam Collagen is temporary, fat
and micronized dermis is intermediate, and
Teflon and Hydroxylapatite is more permanent.
New materials are on the horizon. Hyaluronic
acid and its derivatives, growth factors etc.
Office procedures for injection is promising
Medialization alone
mid - cord gap
Medium gaps 2-3mm
open phase predominates
phonation time >5 sec
positive response to medial compression
testing
flow rates <300 cc/sec
ML under local anesthesia
Isshiki
THYROPLASTY
Placement of Window
4 - 5 mm
8 - 10 mm
Which Material
Silastic
Gortex
Hydroxapatite
Montgomery
THYROPLASTY
Gortex too posterior
Medialization alone
When to do ML?
Mid-cord gap
Permanent gap
Muscle atrophy and not scar
When the gap is larger than 2 mm in the
mid-cord
When levels are the same
Functional Results (intraoperative)
PT >6 sec
dynamic range >20 dB
syllable count >10
frequency is appropriate
no strain or breathiness of voice in a
variety of voice frequencies
Indications for AA & ML
recurrent aspiration with glottic
incompetence in vagal paralysis
post partial laryngectomy with glottic
incompetence
poor voice in vocal cord paralysis
Arytenoid mal-rotation
Level difference
Combined ML and AA
aphonic patient
posterior gap > anterior gap
arytenoid rotation
long-term paralysis
PT<4 sec. flows >300 cc/sec
small phonetograms
High vagal paralysis
Check Arytenoid Position
Don’t make implant too big
Technical Tips
constrictor flap
Isshiki
Technical : remove posterior horn
Pharyngeal constrictor flap
Pre and post AAML
Pre and post video
PO 1 week
PRE-op
PO 3 mo
When to do AA/ML?
When the arytenoid is not right
When there is a posterior chink
When there is a level difference
When you have failed ML alone or
injection alone
Management of Unilateral Vocal Fold
Paralysis
Yes
Potential for recovery?
Patient's functional level
No
Glottic Configuration
No disability
Aspiration
Beathiness
Midglottic gap
Large posterior gap
Different levels
Observation
Speech therapy
Gelfoam injection
Fat injection
Cymetra injection
Collagen injection
Thyroplasty
Teflon injection
Arytenoid adduction
(+/- thyroplasty)
What is New 2009?
Increasing appreciation of vocal fold
paresis as important contributor to
dysphonia
Increasing appreciation of the role of
LEMG
Role of dynamic re-innervation in young
patients and in patients with bilateral VCP
New injectable materials that maybe
permanent