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Awake per-oral vocal fold injection with Calcium Hydroxyapatite

Contributors: Clark A. Rosen

Peroral vocal fold augmentation provides the patient an opportunity for permanent or temporary vocal fold augmentation under local anesthesia, obviating a trip to the operating room and general anesthesia.

DOI: https://doi.org/10.17797/q995b29rk7

Awake per-oral vocal fold injection with Calcium Hydroxyapatite
Vocal fold paralysis, vocal fold paresis, vocal fold atrophy, vocal fold scar, sulcus vocalis, soft tissue loss of the vocal fold(s)
(1) Unstable cardiopulmonary status; (2) Inability to tolerate procedure under local anesthesia (eg. hyperactive gag response or high level of anxiety); (3) Inability to visualize the larynx adequately during the time of injection; (4) Inadequate mouth opening (at least 2-cm intermaxillary distance); (5) Use of anticoagulants (relative contraindication).
The procedure is typically performed with one assistant while the patient sits upright in a chair.1,2 Additional details and educational information for laryngology assistants can be found in the article by Mallur and Rosen.1
Pre-procedure vital signs are taken, including heart rate and blood pressure. Generally a patient is not considered a suitable candidate for unsedated procedures if he or she is anxious and having a difficult time tolerating diagnostic flexible laryngoscopy. A sensitive gag reflex may also preclude the patient from having an unsedated procedure. Other factors to consider include the patient’s anatomy and general health status. The patient must have a sufficiently patent nasal passage to allow a channeled laryngoscope (outer diameter 5.0mm) to pass through. For patients who require cardiopulmonary monitoring, the procedure can be performed in an endoscopy suite or in the OR with continuous monitoring capabilities.
Ideal injection site is anterior to the vocal process along the superior arcuate line. For vocal fold atrophy, the injection can be performed at mid-fold along the superior arcuate line. For vocal fold scar or vocal fold soft tissue loss, injection can be tailored to the vocal fold deficient site.
Advantages: An awake, per-oral injection in the clinic or OR setting allows patients to avoid general anesthesia. There is no need to be NPO before the procedure. However, patients need to be NPO for 2 hours after the procedure given the degree of laryngeal anesthesia administered. The patient is unsedated, thus he or she can drive to and from the clinician’s office before and after the procedure. Post-surgical recovery time is less compared to procedures performed in the OR, which translates into less missing time from work or school. Further, since the procedure is performed with the patient completely awake and in the upright position, vocal fold augmentation can be tailored to optimize the patient’s voice result by intermittently testing the voice throughout and at the completion of the procedure. Disadvantages:
Epistaxis from passing the laryngoscope through the nares, vasovagal reaction, superficial injection, lateral injection into the paraglottic space resulting in insufficient augmentation, inferior injection into the subglottis.
Epistaxis from passing the laryngoscope through the nares, vasovagal reaction, superficial injection, lateral injection into the paraglottic space resulting in insufficient augmentation, inferior injection into the subglottis.
N/A
1. Mallur PS, Rosen CA. Techniques for the laryngology assistant: providing optimal visualization. Operative Techniques in Otolaryngology. 2012; 23(3): 197-202. 2. Rosen CA, Simpson CB. (2008). Operative Techniques in Laryngology. Berlin, Germany. Springer. 3. Mallur PS, Rosen CA. Vocal fold injection: review of indications, techniques, and materials for augmentation. Clin Exp Otorhinolaryngol. 2010; 3(4): 177-82.

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