Gelfoam injection as a treatment for temporary vocal fold paralysis. (Laryngoscopic Clinic).

A 35-year-old woman, a nurse, sought evaluation for hoarseness of 35 days' duration. Her hoarseness had begun suddenly following a surgical procedure to close an infected wound of the coccyx. The surgery had been performed with the patient under general anesthesia and orotracheal intubation. The procedure had been performed without difficulty.

On our examination, laryngovideostroboscopy revealed immobility of the left true vocal fold (figure 1). No other abnormalities were noted. The patient's Voice Handicap Inventory (VHI) score was 69. Laryngeal electromyography (EMG) was performed on the same day to rule out a cricoarytenoid dislocation, and those findings were consistent with a left recurrent laryngeal neuropathy. With the patient under local anesthesia and intravenous sedation, Gelfoam was injected into the left true vocal fold to achieve temporary medialization. Following the injection, the patient reported that her voice and swallowing functions were significantly improved. Her VHI score fell to 48. Examination at 6 days postoperatively revealed a well-medialized left true vocal fold (figure 2).

At the 6-week follow-up, however, no movement of the left true vocal fold was noted. A repeat laryngeal EMG identified fibrillation potentials at rest and no motor unit activation on attempted phonation. These findings were consistent with severe left recurrent laryngeal neuropathy. The prognosis for a spontaneous recovery was unfavorable. (1) Given that only 3 months had passed since the onset of the vocal fold paralysis, repeat Gelfoam injections were suggested on an as-needed basis. However, the patient was lost to follow-up for 6 months. When she did return, examination revealed that her vocal fold mobility was normal, and laryngovideostroboscopy revealed that her mucosal waves were normal bilaterally (figure 3). Nevertheless, examination also detected muscle tension dysphonia, and the patient underwent two sessions of voice therapy. Thereafter, her examination findings were completely normal, and she reported a normal voice without limitations.

The two most likely reasons for a sudden onset of hoarseness following orotracheal intubation are recurrent laryngeal nerve paralysis and cricoarytenoid dislocation. Differentiating between these two possibilities can be facilitated by the use of laryngeal EMG. If EMG shows normal nerve activity, a reduction of the dislocated arytenoid should be performed as soon as possible. Vocal fold paralysis following orotracheal intubation is believed to be caused by a compression injury to the recurrent laryngeal nerve by the cuff of the endotracheal tube. Our experience with vocal foldparalysis following orotracheal intubation includes several patients whose laryngeal EMG findings suggested a poor prognosis, but who subsequently experienced a spontaneous recovery of vocal fold motion.

Gelfoam is made up of bovine gelatin, and it is supplied sterile as either a powder or a foam sheet. The powder can be mixed with 3 to 5 ml of sterile saline to form a paste for vocal fold injection. (2) Likewise, the foam sheeting can be cut into small pieces and mixed vigorously with 3 to 5 ml of saline to form an injectable paste. Gelfoam has a long history of successful, uncomplicated use in many surgical settings.

Optimal results with Gelfoam vocal fold injection are achieved when the injection is placed deep to the vocal fold, adjacent to the thyroid lamina. Gelfoam vocal fold injections can be administered in the operating room with the patient under general anesthesia or in the office (perorally or percutaneously) with the aid of local anesthesia.

Temporary medialization of a paralyzed vocal fold with Gelfoam injection is an excellent method when the prognosis for recovery is unknown. (3) It provides medialization for 4 to 6 weeks, and it can be repeated if necessary without any permanent side effects.

References

(1.) Munin MC, Murry T, Rosen CA. Laryngeal electromyography: Diagnostic and prognostic applications. Otolaryngol Clin North Am 2000;33:759-70.

(2.) Schramm VL, May M, Lavorato AS. Gelfoam paste injection for vocal cord paralysis: Temporary rehabilitation of glottic incompetence. Laryngoscope 1978;88(Pt 1):1268-73.

(3.) Rosen CA. Phonosurgical vocal fold injection: Procedures and materials. Otolaryngol Clin North Am 2000;33: 1087-96.

From the Department of Otolaryngology--Head and Neck Surgery, University of Pittsburgh School of Medicine, and the University of Pittsburgh Voice Center.