HSC Section 6 Nov2016 Green Book

Sunil P. Verma and Seth H. Dailey

OBIL for the Management of UVFP

UVFP often results frommalignancy, surgery, and sometimes both. As mentioned earlier, patients may also have general health concerns, cardiopulomonary compromise, anticoagula- tion needs, as well as psychosocial stressors. As such, the safety of any intervention for this patient population must critically be evaluated. These data, in combination with other data sets, confirm the notion that OBIL is a safe procedure for patients with UVFP. 24,25 One patient had a complication in which vocal fold edema was noted and that the procedure was terminated without incident. There were no complications requiring hospital admission. Patients who were on aspirin prophylactically to prevent cardiac events were asked to stop taking medication 1 week before injection. However, those patients who were taking anticoagulants for therapeutic treatments did not stop taking medications for IL. No complications with hematoma or airway compromise occurred with this approach. For most patients who had injection performed transorally, IL was performed using a 27 gauge needle, in which little, if any, bleeding was noted even if patients were anticoagulated. For this reason, it was deemed safe to continue blood thinners for patients in whom it was medically necessary and do not report any complications with this approach. Others have also shown that procedures performed while a patient is taking anticoagulants are safe. 3,34 There are risks associated with general anesthesia, which is one of the major motivators to performing office-based laryn- geal surgery. Graboyes et al 26 recently published their experi- ence with IL performed under general anesthesia for patients with UVFP after thoracic surgery. Although the majority of their patients did quite well, one of the 20 patients did have in- traoperative bile reflux on induction of anesthesia resulting in pneumonitis that may have been avoided with OBIL. The disposition of patients after injection is shown in Figure 1 . Thirty percent of patients sought a definitive interven- tion in the form of thyroplasty or ansa cervicalis-RLN reinner- vation. These results are similar to a study performed by Arviso et al, 16 in which 29% of patients who underwent IL (in the OR or the office) for UVFP required further definitive intervention with medialization thryoplasty. Sixteen percent of the patients treated by Damrose 25 for UVFP required thryoplasty and/or arytenoid adduction after OBIL. There are multiple reasons why this may have occurred. The concept of laryngeal synkinesis describes abnormal reinnerva- tion of the laryngeal muscles after injury to the RLN. 35–37 After deinnervation of the vocal fold, regeneration of RLN motor axons place the vocal fold in either a favorable or unfavorable position. 37 It has been posited that early medialization of the vocal fold with IL places the vocal fold in a favorable position that is maintained by synkinetic reinnervation. 15 Another consideration is that fibrosis and scarring secondary to IL assist in placing the vocal fold in a permanent medial position. 14,38 Perhaps due to a combination of these reasons, only 30% of the patients in this study required definitive treatment. In the present study, 22% of individuals had a documented return of function and normal voice noted during stroboscopic examination of the larynx. Fourteen percent of the individuals died, and 9% returned to the office, were noted not to have

full recovery of vocal fold motion, and opted for no further intervention. One-quarter of patients did not follow-up. Although this is a sizable number, it is similar to the results of other retrospective studies. 13–16,39 One reason for this is likely due to the large draw of the University of Wisconsin where patients may choose to follow-up with a local otolaryn- gologist or primary care physician. Some of these patients may have had return of normal or near normal voicing and not found a reason to follow-up. Sulica 40 noted that in idiopathic vocal fold paralysis, which was the second most common reason for UVFP in this series, 52% ± 17% of individuals affected re- gained complete recovery of voice. There are limitations to this study which should be recog- nized. All patients were treated by a single-physician and the data were analyzed in a retrospective fashion. Outcome mea- sures were not obtained in this study, so it is not possible to examine how effective OBIL is. However, other studies have demonstrated improvements in voice quality, swallowing abil- ity, and voice-related quality-of-life after OBIL. 13,25 From these data, further questions remain to be answered. Multiple injectates were used and it would be interesting to determine which of these is the most durable. The reasons for patients not opting for a more definitive surgery would also be helpful to know. CONCLUSIONS OBIL is a safe procedure that is well tolerated in the manage- ment of UVFP. Multiple injectates may be used, and familiarity with multiple approaches is beneficial to be able to treat the most number of individuals in the office setting. As noted in this and other studies, a minority of patients who undergo IL require laryngeal framework surgery or a reinnervation procedure. REFERENCES 1. Bruening W. Uber eine neue Behandlungsmethode der Rekurrenslahmung . Verhandl Ver Dtsch Laryngol . 1911;18:93–151. [In German]. 2. Bastian RW, Collins SL, Kaniff T, Matz GJ. Indirect videolaryngoscopy versus direct endoscopy for larynx and pharynx cancer staging. Toward elimination of preliminary direct laryngoscopy . Ann Otol Rhinol Laryngol . 1989;98:693–698. 3. Bastian RW, Delsupehe KG. Indirect larynx and pharynx surgery: a replace- ment for direct laryngoscopy . Laryngoscope . 1996;106:1280–1286. 4. Rosen CA, Thekdi AA. Vocal fold augmentation with injectable calcium hydroxylapatite: short-term results . J Voice . 2004;18:387–391. 5. Ford CN, Bless DM, Loftus JM. Role of injectable collagen in the treatment of glottic insufficiency: a study of 119 patients . Ann Otol Rhinol Laryngol . 1992;101:237–247. 6. Sulica L, Rosen CA, Postma GN, et al. Current practice in injection augmentation of the vocal folds: indications, treatment principles, tech- niques, and complications . Laryngoscope . 2010;120:319–325. 7. Rubin HJ. Dysphonia due to unilateral nerve paralysis. Treatment by the in- tracordal injection of synthetics—a preliminary report . Calif Med . 1965; 102:105–109. 8. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitu- dinal analysis of etiology over 20 years . Laryngoscope . 2007;117: 1864–1870. 9. Davies L, Welch HG. Increasing incidence of thyroid cancer in the United States, 1973-2002 . JAMA . 2006;295:2164–2167.

77