HSC Section 6 Nov2016 Green Book

Journal of Voice, Vol. 28, No. 3, 2014

be injected to the intended completion point using a transoral, transcricothyroid membrane, transthyrohyoid membrane, or transthyroid ala approach. The transoral approach was preferred by the authors as it can be performed by one surgeon, without the need for an assistant. It also allows for the entirety of the needle to be visualized during the injection. The average amount of injectate applied in this population was 0.64 mL. Mau and Courey 28 demonstrated that on average 0.62 and 0.41 mL of calcium hydroxyapatite were necessary to medialize a cadaveric vocal fold via a lateral injection. The in- crease may be a result of the overinejction necessary to account for reabsorption of injectate. Numerous injectates were used in this study, which were tolerated well by most patients. Howev- er, two complications noted in this study were related to the in- jectate used. The first was a hypersensitivity reaction to Restylane. A study of rabbit vocal folds injected with Restylane revealed that at 1 week and 3 months after injection, the vocal folds experienced ‘‘low fibrinogenesis,’’ ‘‘a slight inflammatory reaction and absence of necrosis,’’ and ‘‘granuloma formation and low fibrinogenesis.’’ 29 However, within the Dermatology literature, injection site inflammation resulting in transient redness and edema of the injected site immediately after injec- tion has been noted in 0.02% of individuals who underwent in- jection of hyaluronic acid gel for soft tissue augmentation. 30 Additionally, hypersensitivity and inflammatory reactions to hyaluronic acid gel have been noted after cutaneous injections for management of facial rhytids. 30–32 It is very possible that the patient treated in this series experienced a similar reaction in the vocal fold after injection. The other complication resulted from an injection of calcium hydroxyapatite into the superficial lamina propria, requiring removal under general anesthesia during microlaryngoscopy. This was removed in a manner similar to techniques described by others. 33 Ensuring placement of the injectate into the correct portion of the larynx is paramount in OBIL.

TABLE 3. Injectate Used During OBIL

Number of Times Used (Percent of Total)

Injectate

Hyaluronic acid (Hylaform, Allergan- Inamed Crop, Irvine, CA) Calicium hydroxyapetite (Radiesse Voice, BioForm Medical, San Mateo, CA) Micronized dermis (Cymetra, LifeCell Corp, Branchburgh, NJ) Hyaluronic acid gel (Juvederm Ultra Plus, Allergan, Santa Barbara, CA) Hyaluronic acid (Restylane, Q Med, Uppsala, Sweden)

33 (40.2)

20 (24.4)

14 (17.1)

8 (9.8)

6 (7.3)

Teflon

1 (1.2)

access to resources. In this series, all patients were treated in of- fice. One reason for this is the fact that University of Wisconsin Clinics is a hospital-based practice in which injectables may be billed to the insurance. In a stand-alone clinic, patients are responsible for cost of the injectate, which causes many to elect for procedures in the OR. Additionally, the office laryngeal sur- gery suite is located within the hospital building, allowing both inpatients and outpatients to be examined and treated using the same setup. The average age of patients treated in this series was 60 years which is similar to other reports. 25,27 The left vocal fold was affected more often, which is also consistent with large studies. 8 The most common etiology of paralysis was thoracic which included injury to the recurrent laryngeal nerve (RLN) from mass effect of benign and malignant disease or complica- tions after chest surgery. All patients in this series were able to

FIGURE 2. Disposition of patients after OBIL.

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