Endoscopic Airway Surgery

Hartnick CJ, Hansen MC, Gallagher TQ (eds): Pediatric Airway Surgery. Adv Otorhinolaryngol. Basel, Karger, 2012, vol 73, pp 90–94

Vocal Fold Injection Medialization Laryngoplasty

Vikash K. Modi

Pediatric Otolaryngology, Department of Otolaryngology- Head & Neck Surgery, Weill Cornell Medical College,

New York, N.Y., USA

Abstract

Unilateral vocal fold paralysis (UVFP) can cause glottic

insufficiency that can result in hoarseness, chronic cough,

dysphagia, and/or aspiration. In rare circumstances, UVFP

can cause airway obstruction necessitating a tracheos-

tomy. The treatment options for UVFP include observa-

tion, speech therapy, vocal fold injection medialization

laryngoplasty, thyroplasty, and laryngeal reinnervation.

In this chapter, the author will discuss the technique of

vocal fold injection for medialization of a UVFP.

Copyright © 2012 S. Karger AG, Basel

Unilateral vocal fold paralysis (UVFP) can cause

glottic insufficiency that can result in hoarseness,

chronic cough, dysphagia, and/or aspiration. In

rare circumstances, UVFP can cause airway ob-

struction necessitating a tracheostomy.

Etiologies of pediatric UVFP include birth

trauma, central or peripheral neurologic anoma-

lies, prolonged intubation, anoxia, cardiothoracic

surgery, and idiopathic causes. Spontaneous re-

covery of congenital UVFP has been documented

as late as 4 years of age in a child [1].

The treatment options for UVFP include ob-

servation, speech therapy, vocal fold injection

medialization laryngoplasty, thyroplasty, and la-

ryngeal reinnervation [2].

Materials utilized for vocal fold injection medi-

alization laryngoplasty are autologous fat, gelatin

sponge (Gelfoam; Pfizer, New York, New York),

hydrated porcine gelatin powder (Surgifoam;

Johnson & Johnson, Somerville, New Jersey),

acellular cadaveric dermis (Cymetra; LifeCell,

Branchburg, New Jersey), calcium hydroxylapa-

tite (Radiesse Voice; Bioform Medical, San Mateo,

California), and sodium carboxymethylcellulose

aqueous gel (Radiesse Voice Gel; Bioform Medical,

San Mateo, Calif., USA). Studies [2, 3] have found

a different length of duration for each material

(table 1). Teflon has been long abandoned due to

risk of granuloma formation.

Some authors have found that children injected

with absorbable material will not require a repeat

injection. This is thought to be due to a gradual re-

lateralization of the vocal fold allowing for adequate

compensatory mechanisms to develop [4]. Another

possible explanation is that injection of a material

may induce fibrosis and scar formation, which in-

creases the bulk of the atrophied vocal fold [3].

Indications

• UVFP

– Neonate or infant

◆ Dysphagia

◆ Recurrent aspiration pneumonia

– Older children

Vocal Fold Injection Medialization Laryngoplasty 91

◆ Hoarseness

◆ Chronic cough

◆ Recurrent aspiration pneumonia

Contraindications

• Neonates with no evidence of significant

dysphagia or aspiration

– Since the rate of spontaneous recovery for

UVFP is high in neonates, it is prudent to wait

until a child becomes older prior to performing

an injection medialization laryngoplasty.

(Injection is performed in neonates with

evidence of aspiration or dysphagia to avoid a

gastrostomy tube.)

• Poor endoscopic exposure of the larynx

– Retrognathia

– Micrognathia

– Glossoptosis

– Macroglossia

– Retroflexion of the epiglottis

Anesthesia Considerations

• Spontaneous ventilation without intubation

• Intubation

– Low pulmonary reserve

– Older children when spontaneous ventilation

is not feasible

Preparation

• Modified barium swallow to evaluate

swallowing and aspiration

• Laryngeal EMG

Table 1. Materials for injection medialization thyroplasty

Product Material Duration Pros Cons

Gelfoam bovine gelatin 4– 6 weeks long track record short effect

Surgifoam porcine gelatin 4– 6 weeks short effect

Radiesse voice gel carboxymethylcellulose 2– 3 months no allergy special needle

Radiesse voice calcium hydroxylapatite 2– 5 years long effect special needle

Autologous fat autologous fat months to years no allergy harvest time

Collagen based

Zyplast bovine collagen 4– 6 months long track record skin testing due to

allergy

Cymetra cadaveric dermis 2– 4 months no allergy prep. time

Hyaluronic acid gels

Restalyne hyaluronic acid

bacterial engineered

6– 9 months long effect stiff

Perlane hyaluronic acid

bacterial engineered

6– 9 months long effect stiff

Hyalform hyaluronic acid from rooster

combs

6– 9 months long effect less stiff

Hyalform Plus hyaluronic acid from rooster

combs

6– 9 months long effect less stiff

Chart from C. Blake Simpson, MD, University of Texas and Albert Mareti, MD, Washington University. Duration repre-

sents the length of effect in an adult.

92 Modi

– Polyphasic action potentials or any activity

◆ Consider shorter duration injection material

– No action potentials

◆ Consider longer duration injectable

◆ Consider reinnervation procedure

• If there is no etiology for the vocal cord

paralysis, an MRI brain and neck looking for

any neurologic anomalies should be obtained

• Micro direct laryngoscopy with cricoarytenoid

joint palpation

• Special equipment:

– Parsons laryngoscope

Procedure

• Preoperative antibiotics

• Patient positioned in supine position with

shoulder roll if necessary

• Spray larynx with 1– 4% lidocaine using

atomizer

• Parsons laryngoscope placed in vallecula and

the patient placed in suspension

– Cut 5.5 endotracheal tube connected to side

port of laryngoscope to allow for spontaneous

ventilation

• Visualization with Hopkins rod- lens telescope

(see online suppl. video 1)

• Injection material (table 1)

– Short- duration short- term paresis/paralysis or

in neonates/infants

◆ Gelfoam (1– 1.5 months)

◆ Surgifoam (1– 1.5 months)

◆ Radiesse voice gel (2– 3 months)

– Long duration/long- term paralysis or after

failed short- duration injection

◆ Cymetra (2– 4 months)

◆ Radiesse voice (2– 5 years)

◆ Autologous fat (months to years)

• Injection location

– Lateral to vocal process and lateral to arcuate

line (fig. 1)

– Mid- vocal fold, lateral to arcuate line (fig. 2)

– Inject at the glottis medializing the vocal fold

◆ Stop injection when vocal fold is midline

– Inject into the infraglottis medializing conus

elasticus

◆ Helps generate subglottic pressure when

vocalizing

◆ Continually check for infraglottic extension

with Hopkins rod telescope

– Injection technique

◆ ‘Stair step’ insertion of needle to avoid

extravasation of material: enter mucosa; move

needle 1– 2 mm lateral; push needle in 1– 3 mm

further

– Suction excess material and reassess (fig. 3)

Postoperative Care

• Admission to PICU (age <1 year) or floor (age

>1 year) with continuous pulse oximetry

• Swallow and speech evaluation post operat-

ively

Fig. 1. Preinjection view. Needle is at the first injection

point lateral to vocal process and lateral to arcuate line.

Note that there is no rotation of the vocal process result-

ing in a large posterior glottic gap.

Vocal Fold Injection Medialization Laryngoplasty 93

Pearls

• Continually assess glottic and infraglottic

injection with Hopkins rod- lens telescope

• Smooth out injection into vocal fold with

straight suction

• Avoid subepithelial injection which will

decrease vibratory capacity of vocal fold

– Remove material if subepithelial injection

occurs

• Do not overinject

– Do not inject so vocal fold is past the midline

– Do not overaugment conus elasticus

Case Presentation

This was a 2- year- old male with a history of PDA ligation with a hoarse voice, chronic cough, and recurrent aspi-ration pneumonia. Flexible fiber- optic laryngoscopy was consistent with UVFP. Direct laryngoscopy and bronchos-copy with laryngeal EMG were consistent with good cri-coarytenoid joint mobility with no action potentials of the left thyroarytenoid muscle. Left vocal fold injection me-dialization laryngoplasty was performed. First injection point was lateral to the vocal process and lateral to the ar-cuate line (fig. 1). Second injection point was lateral to the mid- vocal fold and lateral to the arcuate line (fig. 2). Final view is shown in figure 3.

Fig. 2. Needle is at the second injection point lateral to

the mid- vocal fold and lateral to the arcuate line.

Fig. 3. Postinjection view. Left vocal fold is near midline

with some rotation of vocal process.

94 Modi

References

1 Daya H, Hosni A, Bejar- Solar I, Evans JNG, Baily CM: Pediatric vocal fold paralysis: long term prospective study. Arch Otolaryngol Head Neck Surg 2000; 126:21– 25.

2 Sipp JA, Kerschner JE, Braune N, Hart-nick CJ: Vocal fold medialization in chil-dren: injection laryngoplasty, thyro-plasty, or reinnervation? Arch Otolaryngol Head Neck Surg 2007;133: 767– 771.

3 Cohen MS, Mehta DK, Maguire RC, Simons JP: Injection medialization in children. Arch Otolaryngol Head Neck Surg 2011;137:264– 268.

4 Tucker HM: Vocal cord paralysis in small children: principles in manage-ment. Ann Otol Rhinol Laryngol 1986; 95:618– 621.

Vikash K. Modi, MD, FAAP

Weill Cornell Medical College

Pediatric Otolaryngology, Department of Otolaryngology- Head & Neck Surgery

428 East 72nd Street, Suite 100

New York, NY 10021 (USA)

E- Mail vkm2001@med.cornell.edu