vocal fold augmentation - gbmc healthcare · pdf filel rubin and sataloff “vocal fold...
TRANSCRIPT
![Page 1: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/1.jpg)
Vocal Fold Augmentation
Nov 14, 2008Nov 14, 2008Bruce Tan, MD
Sofia Lyford-Pike, MD
![Page 2: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/2.jpg)
CME Objectives
l Discuss the relevant anatomy and pathophysiology of glottic incompetence
l Discuss the use of injectable products for vocal fold medializationvocal fold medialization
l Discuss the surgical techniques available for vocal fold medialization
l Discuss the clinical outcomes of these procedures
![Page 3: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/3.jpg)
![Page 4: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/4.jpg)
l SLN: Cricothyroid musclel RLN: PCA, adductors and
the thyroarytenoidthe thyroarytenoidl RLN de-innervation results in
immediate loss of vocal fold mass, abduction, and adduction producing glottic incompetence
![Page 5: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/5.jpg)
Causes of glottic incompetence
l Vocal cord paralysisl Sulcus vocalisl Vocal fold atrophy
![Page 6: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/6.jpg)
Symptoms of vocal fold incompetence
l Breathy, hoarse, raspy, diplophonic voicel Decreased glottic efficiencyl Aspiration and potentially aspiration pneumonia.pneumonia.
![Page 7: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/7.jpg)
Treatment Modalities
l Voice and swallowing therapyl Vocal cord injectionl Surgery
Treatment Considerationsl Severity of symptomsl Expected duration of impairmentl Patient co-morbidities, motivation
![Page 8: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/8.jpg)
![Page 9: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/9.jpg)
Injection Laryngoplasty
Sofia Lyford-Pike MDSofia Lyford-Pike MDGreater Baltimore Medical Center
Grand Rounds
![Page 10: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/10.jpg)
Vocal Fold Pathology
l Cords that cannot adduct but maintain vibratory characteristics
l Cords move normally but have damaged vibratory membranes
l (Atrophy, scarring, bowing)characteristics
l Dysphonia and…l Aspiration, ineffective cough, dyspnea on exertion
l (Atrophy, scarring, bowing)
l Principal c/o Dysphonia
![Page 11: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/11.jpg)
The Beginningl 1911
Bruening injects Parafin to medialize an immobile cord.-Cons: Inflammatory response, extrusion
and migration
l 1950’sArnold injects cartilage and bovine bone dust -Pro: Less inflammation-Con: Resorption
These 4 facets continue to currently be the limitations in the search for the ideal injectable.
![Page 12: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/12.jpg)
TEFLON1960’sUse: Immobile Cord
PROS Permanent
CONSInflammatory Response
àGranulomasMigration
Difficult InjectionDifficult Injection(not viscous, large gauge
needle)
![Page 13: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/13.jpg)
BOVINE COLLAGEN1980’sUse: Immobile or Poor Vibration
PROSMechanical and Physilogic
Characteristics(both etiologies)
CONSShort Acting(6mos)
HypersensitivityPrecise Administration
Hypersensitivity(skin test b4 injection)
Resorption(overinject 20-30% more)
![Page 14: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/14.jpg)
AUTOLOGOUS COLLAGENUse: Immobile and Poor Vibration
PROSMechanical and Physiologic(comparable to bovine)
No Inflammatory Response
CONSShort Acting (6mos)
Prohibitively Expensive(5cm2 skinà1ml)
No Inflammatory Response(5cm2 skinà1ml)
Resorption
Time Consuming(3mos from harvest to
injection)
![Page 15: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/15.jpg)
CADAVERIC COLLAGEN(Cymetra, Alloderm)Use: Immobile and Poor Vibration
PROSGreat Physiologic
Characteristics
No Inflammatory Response
CONSShort Acting (6mos-9mos, may
need boosters)
ResorptionNo Inflammatory Response
Easy to Obtain
Resorption
![Page 16: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/16.jpg)
AUTOLOGOUS FATUse: Immobile and/or Poor Vibration
PROSBest Physiologic Characteristics
CONSUnpredictable Duration
(approx 3mos)
ResorptionNo Inflammatory
Response
Abundant, uncomplicated harvest
Resorption
![Page 17: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/17.jpg)
Longer Duration NeedNew Developments
l Hydroxylapatite-mineral component of bone-possible permanence of Teflonw/out immune response
-carrier gel absorbs quickly, no need for-carrier gel absorbs quickly, no need foroverinjection, no resorptionTwo Years
l Hyaluronic Acid-organic molecule-viscoelasticity of vocal cord-recruits fibroblasts w/out immune response, softens scars-superior to bovine cartilage in maintaining vibratory characteristicsTwo Years
![Page 18: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/18.jpg)
O’Leary and Grillone 2006
![Page 19: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/19.jpg)
References
l Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007) 1109-1131
l O’Leary, M. Grillone, G. “Injection Laryngoplasty” Otolaryngol Clin N Am 39 (2006) 43-54
![Page 20: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/20.jpg)
Isshiki Type I Thyroplasty
l Cervical incision to gain exposure of thyroid cartilage lamina
l Identify the true vocal linel Design a window inferior to TVC l Design a window inferior to TVC
about 5-10mm from anterior border ~5-6mm in height
l Remove cartilage window while preserving inner perichondrium
![Page 21: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/21.jpg)
Choice of implant materials
l Silasticl Gore-Tex stripl Hydroxyapatitel Titanium
l Key to long term success is initial OVERCORRECTION
![Page 22: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/22.jpg)
Commercially available thyroplasty implants
Montgomery Thyroplasty system (Silastic)
VoCom Thyroplasty system (Hydroxyapatite)
![Page 23: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/23.jpg)
Arytenoid Adduction
l Requires more extensive dissection to expose muscular process of arytenoid
l Enables closure of posterior glottic chink
l Unable to correct bowing or cord atrophy
l Often used in conjunction with medialization thyroplasty
![Page 24: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/24.jpg)
Results
Abraham et al. Laryngoscope 2001
![Page 25: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/25.jpg)
Objective Results
Uloza et al. Eur Arch Otorhinolaryngology 2005
![Page 26: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/26.jpg)
Complications
Abraham et al. Laryngoscope 2001
![Page 27: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/27.jpg)
Conclusions
l Glottic incompetence results in disabling and possibly debilitating problems for the patient
l Injectable or surgical means of augmenting glottic closure can significantly improve glottic glottic closure can significantly improve glottic competence
l The choice of technique for vocal fold augmentation should depend on the severity of symptoms, the expected duration of glottic incompetence and patient factors
![Page 28: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/28.jpg)
CASE STUDY: WLl Hx of right true vocal cord paralysis and persistent hoarseness.
l Vocal cord paralysis onset: 7-8 years ago following a prolonged intubation secondary to medical complications from sepsis. medical complications from sepsis.
l Underwent a tracheostomy and PEG procedure while on the ventilator and attended intense rehabilitation.
l Decannulated/PEG removed w/in one year.
![Page 29: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/29.jpg)
WLl No residual swallowing problems reportedl Hoarseness persisted due to Right vocal cord paralysis.
l A right sided laryngoplasty 2004 without significant vocal improvement. vocal improvement.
l A Cymetra injection 6/07 with significant short-term vocal improvement. Due to the effects of the injection, patient underwent Radiesse injection in 8/08, but no change in hoarse voice quality was achieved.
l Patient no longer works due to his vocal hoarseness.
![Page 30: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/30.jpg)
WLl 1. No mass or ulcerl 2. Right TVC immobile, erythematous, with rigid vibratory activity noted during phonation
l 3. Limited excursion of left true vocal cord noted; vibratory activity on the left WNL
l 4. Supraglottic erythemal 4. Supraglottic erythemal 5. Anterior-posterior compression noted during phonation indicative of hyperfunctional voice use, although this may be compensatory secondary to right TVC paralysis
l 6. Abnormal measures of perturbation with regard to frequency and amplitude; consistent vocal asthenia, strain and roughness
![Page 31: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/31.jpg)
STROBOSCOPY
l
00:56:12 (6:1) - Fully adducted position, medial gap noted at modal pitch
![Page 32: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/32.jpg)
WL
l RECOMMENDATIONS:l 1. Continue GERD Rx and dietary and behavioral management of reflux2. Voice therapy trial, 1x/week for 4-6 weeks, l 2. Voice therapy trial, 1x/week for 4-6 weeks, to maximize vocal strength and reduce hyperfunctional laryngeal behaviors.
![Page 33: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/33.jpg)
CASE STUDY: JE
l JE is a 52 year-old male
l Right true vocal cord paralysis, idiopathic
l s/p bilateral medialization thyroplasty with right arytenoidpexy.
![Page 34: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/34.jpg)
May 2006 JE
![Page 35: Vocal Fold Augmentation - GBMC HealthCare · PDF filel Rubin and Sataloff “Vocal Fold Paresis and Paralysis” Otolaryngol Clin N Am 40 (2007 ... l The choice of technique for vocal](https://reader031.vdocuments.us/reader031/viewer/2022030511/5abbff4b7f8b9ab1118da862/html5/thumbnails/35.jpg)
JEPOSSIBLE BEGINNING SIGNS OF EXTRUSION OF IMPLANT