Office-based procedures for the voice.
Office-based procedures for the voice have become significantly more common in recent years, partly because of the wide variety of injectable augmentation substances that have entered the market. In addition, the indications for using botulinum toxin A botulinum toxin A Oculinum Neurology One of several toxins produced by C botulinum, of which the 150 kD type A toxin has been purified and used to treat various neuromuscular junction disorders including strabismus, blepharospasm, spasmodic torticollis, (Botox) in the larynx have expanded during the past decade. Indeed, it is difficult to envision the practice of laryngology laryngology /lar·yn·gol·o·gy/ (-gol´ah-je) the branch of medicine dealing with the throat, pharynx, larynx, nasopharynx, and tracheobronchial tree.
n. without the armamentarium ar·ma·men·tar·i·um
n. pl. ar·ma·men·tar·i·ums or ar·ma·men·tar·i·a
The complete equipment of a physician or medical institution, including drugs, books, supplies, and instruments. of injectables currently at our disposal.
Although most of these procedures involve a variety of techniques and approaches, we describe those that we use most often and those that are the easiest to learn.
Augmentation injection laryngoplasty
Augmentation injection laryngoplasty is used for the treatment of symptomatic glottal glot·tal
Of or relating to the glottis.
glottal (glot´ insufficiency. Indications include unilateral vocal fold paralysis and vocal fold bowing secondary to muscular atrophy, paresis paresis /pa·re·sis/ (pah-re´sis) slight or incomplete paralysis.
general paresis paralytic dementia; a form of neurosyphilis in which chronic meningoencephalitis causes gradual loss of cortical , or presbylaryngis. A variety of injectables is available, and each has its advantages and limitations (table 1). The choice of substance can be matched to the patient's clinical situation.
The injection technique we prefer is a transoral approach guided by fiberoptic laryngoscopy. Local anesthesia should be administered according to the protocol described in the preceding article in this supplement ("Topical anesthesia of the airway and esophagus," page 2).
Vocal fold paralysis. For treating vocal fold paralysis, we prefer to inject collagen in most cases. (1-3) Note that most injectables must be transferred to a 1-ml tuberculin tuberculin /tu·ber·cu·lin/ (-lin) a sterile solution containing the growth products of, or specific substances extracted from, the tubercle bacillus; used in various forms in the diagnosis of tuberculosis; see also under test. syringe that is loaded into an orotracheal injector (Medtronic Xomed; Jacksonville, Fla.) (figure 1, A). A 27-gauge needle is advanced into the oral cavity under direct vision (figure 1, B). As the needle enters the oral cavity, the patient is instructed to say "aaaah"; this action raises the palate and clears the path into the oropharynx oropharynx /oro·phar·ynx/ (-far´inks) the part of the pharynx between the soft palate and the upper edge of the epiglottis.
n. . The surgeon's assistant should position the fiberoptic scope just above the palate until the needle is seen in the oropharynx. The injector is then advanced and the needle tip is guided into the hypopharynx (still under endoscopic en·do·scope
An instrument for examining visually the interior of a bodily canal or a hollow organ such as the colon, bladder, or stomach.
en visualization) as the assistant follows closely behind with the fiberoptic scope. The assistant must be adept at manipulating the scope because consistent visualization of the injector can be problematic in a narrow airway with copious secretions. The fiberoptic scope should be positioned a few millimeters above the vocal fold. A clear and well-illuminated magnified view of the vocal folds is crucial to achieving the necessary precision (figure 1, C).
[FIGURE 1 OMITTED]
In the case of unilateral vocal fold paralysis, the injection should be placed at two sites: at the posterior aspect (lateral to the vocal process) and at the mid-vocal fold. The injection should be deep enough to reach into the substance of the thyroarytenoid muscle at the level of the free edge of the vocal fold. The surgeon should avoid making a superficial placement into Reinke's space because this will result in a stiff vocal fold and poor voice quality. Conversely, if the subglottis or infraglottis begins to bulge during injection, the needle should be withdrawn slightly. The injection should begin at the posterior aspect of the vocal fold, where the most correction is needed (figure 1, D). Once the posterior vocal fold is adequately medialized, a smaller additional amount can be deposited into the mid-vocal fold (figure 1, E). If the injected substance extrudes from the puncture hole, the material can be cleared by instructing the patient to cough or clear the throat. The injection should be carried out in a stepwise stepwise
incremental; additional information is added at each step.
stepwise multiple regression
used when a large number of possible explanatory variables are available and there is difficulty interpreting the partial regression fashion, and the surgeon should periodically check to see if there is any improvement in the patient's voice.
With most injectables, the medialized vocal fold should be overinjected (past the midline mid·line
A medial line, especially the medial line or plane of the body.
n the line equidistant from bilateral features of the head. ) by approximately 30%. In general, the vocal fold is medialized until the voice is maximally improved. Then an additional 0.1 to 0.2 ml is injected to achieve overcorrection o·ver·cor·rec·tion
An adjustment that surpasses a set criterion, especially of a desired behavior. . This overcorrection is necessary because almost all injectables have a small aqueous component that will be absorbed 3 to 5 days after injection. The total amount necessary for unilateral augmentation is typically less than 1 ml.
Vocal fold bowing. The injection technique used to treat vocal fold bowing secondary to muscular atrophy, paresis, or presbylaryngis differs slightly from the aforementioned technique. Typically, these cases require injection principally into the mid-vocal fold, where the maximal glottal gap occurs (figure 2). In severe cases of muscular atrophy, the posterior vocal fold can be augmented to fill in the atrophy that occurs just anterior to the vocal process. Again, overcorrection is the rule, even in the case of bilateral injections. Airway compromise should not be a concern because the posterior respiratory glottis glottis /glot·tis/ (glot´is) pl. glot´tides [Gr.] the vocal apparatus of the larynx, consisting of the true vocal cords and the opening between them.glot´tal
n. pl. remains patent.
[FIGURE 2 OMITTED]
A Bruning syringe can be used to inject collagen, but this instrument is better suited for delivering large-particle injectables (e.g., Gelfoam and fat) that require an 18- or 19-gauge needle. In addition, the mechanics of this injection device are not as smooth and precise as are those of other injection devices; with the Bruning device, the surgeon must rely on a clicking action that deposits a predetermined pre·de·ter·mine
v. pre·de·ter·mined, pre·de·ter·min·ing, pre·de·ter·mines
1. To determine, decide, or establish in advance: amount of substance (~0.2 ml).
Laryngeal laryngeal /lar·yn·ge·al/ (lah-rin´je-al) pertaining to the larynx.
la·ryn·geal or la·ryn·gal
Of, relating to, affecting, or near the larynx. Botox injection
Botox is very useful in the treatment of a variety of voice disorders, and it is a staple in most laryngologists' offices. The number of uses continues to expand; a few of the more common indications are spasmodic dysphonia, recurrent vocal process granuloma granuloma /gran·u·lo·ma/ (gran?u-lo´mah) pl. granulomas, granulo´mata an imprecise term for (1) any small nodular delimited aggregation of mononuclear inflammatory cells, or (2) such a collection of modified macrophages , paroxysmal paroxysmal (per´ksiz´ml),
adj recurring in paroxysms. laryngospasm, and paradoxical vocal fold movement disorder. Botox is a chemodenervation agent that weakens the target muscle by preventing acetylcholine acetylcholine (əsēt'əlkō`lēn), a small organic molecule liberated at nerve endings as a neurotransmitter. It is particularly important in the stimulation of muscle tissue. release at the motor end plate. The effect on the muscle is temporary, lasting an average of 3 months.
In our practices, most laryngeal Botox injections are performed transcervically under electromyographic guidance to localize lo·cal·ize
v. lo·cal·ized, lo·cal·iz·ing, lo·cal·iz·es
1. To make local: decentralize and localize political authority.
2. the target muscles. This method is the quickest and most precise means of delivering Botox, but the learning curve is steep. Also, it is not intuitive for most otolaryngologists, who prefer direct visualization of the target rather than blind needle trajectory paths. For many otolaryngologists who perform laryngeal Botox injections on an infrequent basis, transoral injection may be the preferred approach.
The equipment setup and local anesthesia technique are similar to those used for the laryngeal procedures described in the previous section. A 100-unit vial of Botox is diluted with 4 ml of preservative-free normal saline, bringing the concentration to 2.5 units per 0.1 ml. An orotracheal injector with a 27-gauge needle is used. The needle should be primed with the solution; this typically requires 0.2 ml.
We use two methods of Botox injection; one is directed at the false vocal folds (figure 3), (4,5) and the other is targeted to the true vocal folds (table 2). The onset of maximum effect typically takes 3 to 7 days. Breathiness or whisper-voice following injection is normal, but it generally resolves in 1 to 2 weeks. A longer breathy breath·y
adj. breath·i·er, breath·i·est
Marked by or as if by audible or noisy breathing: a breathy voice.
breath phase should prompt the surgeon to lower the dose of subsequent injections.
[FIGURE 3 OMITTED]
We continue to advocate microlaryngoscopy under general anesthesia as the gold standard for the removal or biopsy of glottic lesions. In particular, most benign lesions of the vocal folds (e.g., polyps Polyps
A tumor with a small flap that attaches itself to the wall of various vascular organs such as the nose, uterus and rectum. Polyps bleed easily, and if they are suspected to be cancerous they should be surgically removed. , cysts, and nodules Nodules
A small mass of tissue in the form of a protuberance or a knot that is solid and can be detected by touch.
Mentioned in: Leprosy ) require precise dissection techniques to preserve the vibratory vibratory /vi·bra·to·ry/ (vi´brah-tor?e) vibrating or causing vibration.
vibrating or causing vibration; vibritile. characteristics of the vocal folds. The required degree of precision cannot be achieved with an office-based procedure. However, in carefully selected patients with laryngeal lesions, office biopsies can be successful. Moreover, patients who are not good surgical candidates because of coexisting medical morbidities and patients whose anatomy precludes rigid laryngoscopy may be ideal candidates for office-based biopsies.
Using the standard setup for a fiberoptically monitored laryngeal procedure, the surgeon uses a curved laryngeal biopsy forceps (Medtronic Xomed) to biopsy or remove suspicious lesions (figure 4, A). Another method involves the use of a transnasal esophagoscope e·soph·a·go·scope
An endoscope for examining the interior of the esophagus.
an endoscope for examination of the esophagus. with a 1.8-mm biopsy forceps placed through the side channel (figure 4, B). In the case of medically infirm INFIRM. Weak, feeble.
2. When a witness is infirm to an extent likely to destroy his life, or to prevent his attendance at the trial, his testimony de bene esge may be taken at any age. 1 P. Will. 117; see Aged witness.; Going witness. patients with advanced head and neck cancer who are not surgical candidates, a complete panendoscopy can be performed in the office using a transnasal esophagoscope. (6)
[FIGURE 4 OMITTED]
As previously mentioned, most benign lesions should be removed in the operating room with the patient under general anesthesia. But as better instrumentation (figure 5) for lesion removal and dilation dilation /di·la·tion/ (di-la´shun)
1. the act of dilating or stretching.
1. of strictures becomes available, the use of office-based procedures will continue to expand.
[FIGURE 5 OMITTED]
Table 1. Laryngeal injectables Length Needle Material of effect Advantages Disadvantages gauge * Gelfoam 6 wk Long track Short duration; 18 or 19 record; minimal some preparation tissue time is required reactivity; can (to mix with be used as a saline). "diagnostic test" in questionable cases of glottal insufficiency. Bovine 4 to 6 mo Small-gauge Allergy test 27 collagen needle can required (Zyplast) be used. (1 mo delay). Autologous 4 to 6 mo No allergy Must harvest 27 collagen test required donor skin (Autologen) (patient's own (4- to 6-wk tissue). processing). Micronized 2 to 6 mo No allergy test Unpredictable 26 or 27 AlloDerm required. length of (Cymetra) effect. Teflon Permanent Long lasting. Irreversible; 18 or 19 may cause vocal fold stiffness; risk of granuloma formation. Calcium 2 to 5 yr Long lasting; Limited track 25 hydroxyapatite (?) FDA approved. record; (Radiance FN) long-term effects unknown. * Gelfoam will not pass through smaller-gauge needles, so a Bruning-type syringe is typically used with an 18- or 19-gauge needle. Collagen (all forms listed) can he injected through a small-gauge needle, such as that supplied with the orotracheal injector (Medtronic Xomed). Micronized AlloDerm can be injected through a small-gauge needle (26 or 27), but some clinicians believe that longer-term results occur if a larger-gauge needle is used (18 to 21). Calcium hydroxyapatite willpass through a 25-gauge needle, but it tends to solidify rapidly inside the lumen of the needle; for this reason, disposable needles (supplied by Bioform Medical; Franksville, Wis.) are recommended. Table 2. Techniques for Botox injection Technique Dose * Location Depth Pros/cons False vocal 5 to 7.5 U Lateral, Superficial Gradual, smooth fold in each fold midfold (mucosal bleb) onset; less (0.2 to breathiness; does 0.3 ml in not last as long each side) (8 to 10 wk). True vocal 2.5 U in Lateral Deep into the More abrupt fold each fold to vocal thyroarytenoid onset; more (0.1 ml in process and lateral breathiness; may each side cricoarytenoid last longer (>3 mo). * Dilution: 4 ml of preservative-free saline in a 100-U vial of Botox. The doses listed are intended to serve as guidelines; they may be raised or lowered depending on how the patient responds.
(1.) Ford CN, Martin DW, Warner TF. Injectable collagen in laryngeal rehabilitation. Laryngoscope 1984;94:513-18.
(2.) Ford CN, Bless DM. Clinical experience with injectable collagen for vocal fold augmentation. Laryngoscope 1986;96:863-9.
(3.) Remacle M, Marbaix E, Hamoir M, et al. Correction of glottic glot·tic
1. Of or relating to the tongue.
2. Of or relating to the glottis.
pertaining to (1) the glottis, or (2) the tongue. insufficiency by collagen injection. Ann Otol Rhinol Laryngol 1990;99:438-44.
(4.) Kendall KA, Leonard RJ. Treatment of ventricular dysphonia dysphonia /dys·pho·nia/ (-fo´ne-ah) a voice impairment or speech disorder.dysphon´ic
Difficulty in speaking, usually evidenced by hoarseness. with botulinum toxin. Laryngoscope 1997;107:948-53.
(5.) Schonweiler R, Wohlfarth K, Dengler R, Ptok M. Supraglottal su·pra·glot·tal
1. Above or anterior to the glottis.
2. Relating to or articulated by the speech organs anterior to the glottis. injection of botulinum toxin type A botulinum toxin type A
Botox, Botox Cosmetic, Dysport (UK), Vistabel (UK)
Pharmacologic class: Neurotoxin
Therapeutic class: Neuromuscular blocker
Pregnancy risk category C
Actionin adductor adductor /ad·duc·tor/ (ah-duk´tor) [L.] that which adducts, as the adductor muscle.
n. type spasmodic dysphonia with both intrinsic and extrinsic hyperfunction. Laryngoscope 1998;108:55-63.
(6.) Postma GN, Bach KK, Belafsky PC, Koufman JA. The role of transnasal esophagoscopy in head and neck oncology. Laryngoscope 2002;112:2242-3.