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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.

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

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

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.’’

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.

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.

Ensuring placement of the injectate into the correct

portion of the larynx is paramount in OBIL.

TABLE 3.

Injectate Used During OBIL

Injectate

Number of

Times Used

(Percent of Total)

Hyaluronic acid (Hylaform, Allergan-

Inamed Crop, Irvine, CA)

33 (40.2)

Calicium hydroxyapetite (Radiesse

Voice, BioForm Medical, San

Mateo, CA)

20 (24.4)

Micronized dermis (Cymetra, LifeCell

Corp, Branchburgh, NJ)

14 (17.1)

Hyaluronic acid gel (Juvederm Ultra

Plus, Allergan, Santa Barbara, CA)

8 (9.8)

Hyaluronic acid (Restylane, Q Med,

Uppsala, Sweden)

6 (7.3)

Teflon

1 (1.2)

FIGURE 2.

Disposition of patients after OBIL.

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