Change to earlier surgical interventions: contemporary management of unilateral vocal fold paralysis Declan Costello

Purpose of review The management of unilateral vocal fold paralysis has undergone significant changes in the last 2 decades. This has largely been made possible by advances in endoscope technology and new injectable materials. Recent findings This article will cover the main changes in management of patients with unilateral vocal fold paralysis and summarize the recent literature in relation to early intervention in this group. Several recent studies have suggested that early vocal fold injection medialization reduces the likelihood of needing open laryngeal framework surgery in future. Summary Early injection medialization appears to give good long-term results with few complications and minimizes the need for future laryngeal framework surgery. It should be considered in centres wherein the equipment and trained staff are available. Keywords injection laryngoplasty, injection medialization, medialization laryngoplasty, thyroplasty, vocal fold paralysis

INTRODUCTION The advent of high-quality distal-chip flexible endoscopes has allowed for high-resolution imaging of the aerodigestive tract in the clinic room, without the need for rigid per-oral endoscopy. This has given rise to a greater array of laryngeal procedures being performed in the awake patient, facilitating rapid treatment of patients, some of whom might otherwise have been deemed too unwell for intervention. These procedures include transnasal oesophagoscopy, balloon dilatations, laser treatments and various injections. In particular, this technological change has radically altered the management of unilateral vocal fold paralysis (UVFP) in the last 2 decades: the rise of injection laryngoplasty (injection medialization) under local anaesthetic has resulted in a significant change in practice for many laryngologists.

BACKGROUND Historically, patients with UVFP would have been offered a period of voice therapy and ‘watchful waiting’. Typically, a patient would have been

expected to wait for up to 12 months until definitive treatment was offered: this was to allow time either for the vocal fold to recover function or for compensation to occur such that the opposite vocal fold worked more efficiently to achieve glottic closure. For many patients, this would have led to a year of difficulty communicating and (frequently) problems with swallowing. At the end of this period, in the absence of adequate improvement, patients would have been offered a permanent surgical treatment in the form of vocal fold medialization: this would constitute either an injection under general anaesthetic or laryngeal framework surgery. Injection medialization under general anaesthetic would have employed Teflon (which has Queen Elizabeth Hospital, Edgbaston, Birmingham, UK Correspondence to Declan Costello, MA, MBBS, FRCS (ORL-HNS), Consultant ENT Surgeon and Laryngologist, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2GW, UK. Tel: +44 121 317 4680; fax: +44 121 371 3421; e-mail: [email protected] Curr Opin Otolaryngol Head Neck Surg 2015, 23:181–184 DOI:10.1097/MOO.0000000000000156

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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Speech therapy and rehabilitation

KEY POINTS  The management of vocal fold paralysis has changed over the last 2 decades, driven by higher patient expectations, improved technology and new medialization materials.  The period of ‘watchful waiting’ for up to 12 months following onset of vocal fold paralysis should be challenged and early intervention considered.  Early intervention with injection laryngoplasty is beneficial for the patient and appears to reduce the likelihood of patients subsequently needing laryngeal framework surgery.

now fallen out of favour because of significant adverse effects) or Vox (polydimethylsiloxane elastomer, previously known as bioplastique). Medialization laryngoplasty (Isshiki type 1 thyroplasty) is generally performed under local anaesthetic in the sedated patient. A window is fashioned in the thyroid cartilage at the level of the paralysed vocal fold and an implant is inserted. It is considered important to perform the surgery under local anaesthetic so that the position of the implant can be checked endoscopically during the procedure and the patient can phonate when the implant is inserted, allowing the position and size of the implant to be altered as required. A range of implants is available – Silastic is a common choice and can be cut to the appropriate size and shape, according to the configuration of the glottic gap; Gore-Tex (W.L. Gore and Associates, Scottsdale, Arizona, USA) ribbon is also popular. Thyroplasty has been considered the ‘gold standard’ of treatment for vocal fold paralysis for many years and still represents an excellent option for many patients. Arytenoid repositioning procedures are performed in cases in which the arytenoid cartilage lies in a suboptimal position (in other words, where there is a large posterior glottic gap). Arytenoid adduction, arytenopexy and cricothyroid subluxation are relatively technically challenging operations, but are useful in certain selected cases. As with thyroplasty, these procedures are performed under local anaesthetic in the sedated patient.

DRIVERS FOR CHANGE IN PRACTICE Advances in endoscope technology (particularly the development of distal chip flexible endoscopes) have allowed for much higher definition images to be captured; this has resulted in clinicians being able to perform a greater range of procedures in the aerodigestive tract with great precision. 182

In parallel with this, injection materials have advanced, utilizing smaller needles that facilitate injection of materials transcutaneously. These injection materials have meant that longer lasting injectable materials can be passed through a relatively small (26G) needle. Specifically, Radiesse Voice (Merz Pharma; calcium hydroxylapatite) is now in widespread use both as a transcutaneous and per-oral injectable: its durability is said to make it ‘semipermanent’, with a duration of effect of around 18 months [1]. Restylane and Restylane Perlane (Galderma; preparations of hyaluronic acid) have both been widely used to achieve temporary medialization. Radiesse Voice Gel is a further temporary injectable material, but at time of writing is not available in Europe.

ADVANTAGES OF INJECTION LARYNGOPLASTY IN THE CLINIC ROOM There are many advantages of transcutaneous injection in the awake patient: it allows for close monitoring of the injection, with real-time monitoring of voice change, real-time monitoring of degree of medialization and (if there is a concern) monitoring of the airway. Voice outcomes have been shown to be good [2–4] and patient satisfaction is high. Patients who would be deemed unsuitable for general anaesthesia or sedation are rarely excluded from injection laryngoplasty; thus, patients who are terminally ill can now be considered for medialization injection to assist in their palliative care, rehabilitating their voice and swallow. The degree of improvement in quality of life in the palliative situation cannot be overestimated [5]. Furthermore, treatment can be offered immediately in the clinic room or office, rather than having to schedule a procedure in the operating room. Complication rates are low (around 2–3%) [1,4,6,7]. From the patient’s perspective, the procedure can be performed quickly and they can leave the clinic shortly after it is completed. Given the choice of medialization laryngoplasty in the operating room or injection laryngoplasty in the clinic, many patients choose the option of an injection medialization under local anaesthetic, particularly if they have recently had major neck surgery; for these patients, the prospect of further open-neck surgery for a thyroplasty is difficult to contemplate and, when offered the option, most choose an injection under local anaesthetic. Patient tolerance is high, with 93% of patients reporting that they would undergo another procedure if necessary; 96% would recommend the procedure to other patients [8]. Volume 23  Number 3  June 2015

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Change to earlier surgical interventions Costello

CHANGING PARADIGMS It can thus be seen that injection medialization laryngoplasty under local anaesthetic has many potential advantages. One perceived disadvantage is the lack of permanence of the injectable materials: even the longest lasting injectable material has a median duration of around 18 months [1]. However, as will be discussed further, even after the material has resorbed, long-lasting beneficial effects may be seen. The relative ease of injection laryngoplasty has prompted earlier and earlier interventions in UVFP. Indeed, an early injection can rapidly assist a patient in returning to work and daily activities. In cases where resolution can be expected, an early injection with a temporary material is an excellent option. Equally, an injection may give significant improvement in swallowing function and resolution of aspiration; this can be particularly helpful in patients who have recently undergone complex neck or thoracic surgery. In the immediate postoperative period following major surgery, injection laryngoplasty can be seen as one of the rehabilitative tools that can expedite discharge from hospital [9]. Furthermore, several recent studies [10–14,15 ] have discussed the long-term benefits of intervening early after the onset of the UVFP. Given that injection materials resorb in the longer term, one might have expected that patients’ voices would return to their baseline (preinjection) state. However, a series of articles has shown that early injection laryngoplasty frequently results in good long-term outcomes and reduces the likelihood of the patient requiring laryngeal framework surgery in the future. Alghonaim et al. [10] performed a retrospective review of 66 patients who underwent transcutaneous injection medialization. The patients were stratified according to the time from onset of UVFP to injection: an ‘immediate’ group (6 months). Success (defined as not requiring subsequent type 1 thyroplasty) was found to be significantly more likely in patients who had had an ‘immediate’ or an ‘early’ injection. It should be noted that all of these injections were performed using temporary materials [Gelfoam (Pfizer), collagen, Perlane or a combination], so the long-lasting benefits cannot be explained by longevity of the injection materials. Similar results were seen in a group of 35 patients [11]. Restylane (hyaluronic acid, a temporary filler) was used. Of the 32 patients who had an ‘early’ (6 months) group later required laryngeal framework surgery. &

Equally, Yung et al. [12] retrospectively evaluated 54 patients who sustained UVFP. Patients who underwent injection laryngoplasty (with one of two temporary materials, Restylane or Radiesse Voice Gel) were significantly less likely subsequently to undergo type 1 thyroplasty. These findings were further corroborated by the same group in a subsequent study [13]. A 2014 article [14] showed Restylane to be a well tolerated injection material. Although its duration of effect in this study was shown to be around 12 weeks, there was further evidence that an early injection (within 6 months of onset of vocal fold paralysis) showed a trend towards avoidance of subsequent requirement for permanent medialization. It is generally considered that larger glottic gaps are more likely to require thyroplasty in the long term. This would intuitively seem logical as it is often difficult to inject sufficient material to achieve glottic closure. This is borne out in a study by Fang et al. [15 ], who used the size of the glottic gap to predict future requirement for thyroplasty: a large gap was found to correlate with future requirement for thyroplasty. However, they also established that, even when a large gap was found at presentation, an early injection substantially reduced the need for thyroplasty later on. &

CONCLUSION The management of UVFP is evolving [6,16]. Although previously laryngologists would have recommended a period of voice therapy and ‘watchful waiting’ for up to 12 months, early injection laryngoplasty, either with a temporary or semipermanent material, is increasingly becoming the norm. Recent evidence suggests that early injection laryngoplasty gives good long-term results and reduces the likelihood of requiring medialization laryngoplasty (type 1 thyroplasty) in the future. In centres with the appropriate equipment and trained staff, strong consideration should be given to early injection under local anaesthetic. Furthermore, even patients with a relatively large glottic gap at presentation benefit from early injection laryngoplasty, and performing such injections does not rule out a future thyroplasty. Acknowledgements None. Financial support and sponsorship None. Conflicts of interest The author has received honoraria from Merz to provide training in injection laryngoplasty.

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Speech therapy and rehabilitation

REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest

1. Carroll TL, Rosen CA. Long-term results of calcium hydroxylapatite for vocal fold augmentation. Laryngoscope 2011; 121:313–319. 2. Birkent H, Sardesai M, Hu A, Merati AL. Prospective study of voice outcomes and patient tolerance of in-office percutaneous injection laryngoplasty. Laryngoscope 2013; 123:1759–1762. 3. Upton DC, Johnson M, Zelazny SK, Dailey SH. Prospective evaluation of office-based injection laryngoplasty with hyaluronic acid gel. Ann Otol Rhinol Laryngol 2013; 122:541–546. 4. Powell J, Carding P, Birdi R, Wilson JA. Injection laryngoplasty in the outpatient clinic under local anaesthetic: a case series of sixty-eight patients. Clin Otolaryngol 2014; 39:224–227. 5. Kupferman ME, Acevedo J, Hutcheson KA, Lewin JS. Addressing an unmet need in oncology patients: rehabilitation of upper aerodigestive tract function. Ann Oncol 2011; 22:2299–2303. 6. Sulica L, Rosen CA, Postma GN, et al. Current practice in injection augmentation of the vocal folds: indications, treatment principles, techniques, and complications. Laryngoscope 2010; 120:319–325. 7. Rosen CA, Gartner-Schmidt J, Casiano R, et al. Vocal fold augmentation with calcium hydroxylapatite: twelve-month report. Laryngoscope 2009; 119: 1033–1041.


8. Young VN, Smith LJ, Sulica L, et al. Patient tolerance of awake, in-office laryngeal procedures: a multiinstitutional perspective. Laryngoscope 2012; 122:315–321. 9. Graboyes EM, Bradley JP, Meyers BF, Nussenbaum B. Efficacy and safety of acute injection laryngoplasty for vocal cord paralysis following thoracic surgery. Laryngoscope 2011; 121:2406–2410. 10. Alghonaim Y, Roskies M, Kost K, Young J. Evaluating the timing of injection laryngoplasty for vocal fold paralysis in an attempt to avoid future type 1 thyroplasty. J Otolaryngol Head Neck Surg 2013; 42:24. 11. Friedman AD, Burns JA, Heaton JT, Zeitels SM. Early versus late injection medialization for unilateral vocal cord paralysis. Laryngoscope 2010; 120: 2042–2046. 12. Yung KC, Likhterov I, Courey MS. Effect of temporary vocal fold injection medialization on the rate of permanent medialization laryngoplasty in unilateral vocal fold paralysis patients. Laryngoscope 2011; 121:2191–2194. 13. Prendes BL, Yung KC, Likhterov I, et al. Long-term effects of injection laryngoplasty with a temporary agent on voice quality and vocal fold position. Laryngoscope 2012; 122:2227–2233. 14. Halderman AA, Bryson PC, Benninger MS, Chota R. Safety and length of benefit of restylane for office-based injection medialization: a retrospective review of one institution’s experience. J Voice 2014; 28:631–635. 15. Fang TJ, Pei YC, Li HY, et al. Glottal gap as an early predictor for permanent & laryngoplasty in unilateral vocal fold paralysis. Laryngoscope 2014; 124: 2125–2130. This article reinforces other published research that suggests that early injection can reduce the likelihood of subsequently requiring thyroplasty. It also highlights the fact that a large glottal gap is a predictor for requirement for subsequent thyroplasty. 16. Mallur PS, Rosen CA. Office-based laryngeal injections. Otolaryngol Clin North Am 2013; 46:85–100.

Volume 23  Number 3  June 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Change to earlier surgical interventions: contemporary management of unilateral vocal fold paralysis.

The management of unilateral vocal fold paralysis has undergone significant changes in the last 2 decades. This has largely been made possible by adva...
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