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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 al26 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 Damrose25 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. Sulica40 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
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Sunil P. Verma and Seth H. Dailey OBIL for the Management of UVFP
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