In-Office Laryngology Injections

Dysphagia in Head and Neck Cancer

Dysphagia is a common symptom in patients with head and neck cancer that can significantly impact health outcomes and quality of life. The origin of dysphagia in these patients is often multifactorial, making diagnosis and management especially complex. The evaluating otolaryngologist should be well versed with the patient's neoplasm, comorbidities, and treatment history alongside dysphagia-specific imaging modalities. Management is often dynamic, requiring frequent monitoring, interprofessional collaboration, and a variety of supportive and invasive measures to achieve optimal outcomes.

The Long Term Results of Hyaluronic Acid/Dextranomer Injection Laryngoplasty in Unilateral Vocal Fold Paralysis

OBJECTIVE

This study was conducted to present the long-term functional outcomes of injection laryngoplasty (IL) with hyaluronic acid/dextranomer (HA/D) in unilateral vocal fold paralysis (UVFP).

METHODS

A total of 40 patients who underwent HA/D injection for UVFP were enrolled. The acoustic analysis of the voice was evaluated with jitter percentage, shimmer percentage, maximum phonation time, harmonics-to-noise ratio, and fundamental frequency. The psychosocial effect of the voice was determined using the Voice Handicap Index-10. Fiberoptic endoscopic evaluation of swallowing was performed and 2 scales were used for quantification: a modified penetration-aspiration scale and a dysphagia score. All measurements were performed at preoperative day and postoperative months 1, 6, and 24.

RESULTS

A statistically significant improvement was observed for all of the evaluated parameters except the maximum phonation time for postoperative months 1, 6, and 24 (P < .05). In the evaluation of the maximum phonation time, although there was a significant improvement for the postoperative months 1 and 6, no significant difference was observed between the postoperative 24th month and the preoperative value.

CONCLUSIONS

HA/D injection laryngoplasty is an effective method both in the short- and long-term to improve voice and swallowing functions in patients with UVFP.

Tissue Engineering as a Promising Treatment for Glottic Insufficiency: A Review on Biomolecules and Cell-Laden Hydrogel

Glottic insufficiency is widespread in the elderly population and occurs as a result of secondary damage or systemic disease. Tissue engineering is a viable treatment for glottic insufficiency since it aims to restore damaged nerve tissue and revitalize aging muscle. After injection into the biological system, injectable biomaterial delivers cost- and time-effectiveness while acting as a protective shield for cells and biomolecules. This article focuses on injectable biomaterials that transport cells and biomolecules in regenerated tissue, particularly adipose, muscle, and nerve tissue. We propose Wharton's Jelly mesenchymal stem cells (WJMSCs), induced pluripotent stem cells (IP-SCs), basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), hepatocyte growth factor (HGF), insulin growth factor-1 (IGF-1) and extracellular vesicle (EV) as potential cells and macromolecules to be included into biomaterials, with some particular testing to support them as a promising translational medicine for vocal fold regeneration.

Device Failure During Injection Medialization Laryngoplasty

OBJECTIVES

Injection medialization laryngoplasty is a commonly performed procedure for the management of glottic insufficiency. Among complications of this procedure is device failure, for which the literature is scarce. Our goal was to determine the prevalence of needle failure during injection laryngoplasty among members of the American Bronchoesophagological Association (ABEA).

METHODS

A questionnaire was designed and subsequently sent to members of ABEA via electronic mail. Responses were analyzed using descriptive statistics.

RESULTS

Twenty-four members (6.7%) completed the survey. Eighty three percent reported experience with needle failure; 59% of these were needle clogging, 22% needle twisting, and 19% needle tip fracture. Fifty-four percent of respondents reported needle failure during a percutaneous approach, and 48% reported using calcium hydroxyapatite during device failure. Twenty percent reported having to abort the procedure due to device failure. Twenty five percent of respondents experienced needle tip fracture that led to an airway or esophageal foreign body.

CONCLUSIONS

Needle failure during injection laryngoplasty was reported by most respondents. Most commonly this was due to clogging or twisting which was managed by replacing the needle but in 25% of cases was due to a broken tip that results in an aerodigestive tract foreign body and aborting of the procedure in most cases.

Variations in Practices and Preferences of Vocal Fold Injection Materials: A National Survey

BACKGROUND

Vocal fold injection augmentation (VFI) is a common procedure for the treatment of glottic insufficiency. Material options for VFI and decisions regarding material selection are not standardized and often based on clinician preference.

OBJECTIVE

This study aims to understand the variations in provider preference and utilization of injectable materials for VFI.

METHODS

A 40-question survey was sent to 158 academic laryngologists. Questions pertained to the type of injectable materials used including brand preferences and rationale for preferences.

RESULTS

Ninety-seven of the 158 laryngologists contacted participated in the survey (61.4%). The most frequently used injectable materials were Hyaluronic Acid (HA)-based products. Carboxymethylcellulose (CMC)-based products were preferred for trial augmentation (57.2%), HA-based products were preferred for acute/subacute vocal fold paralysis, presbyphonia, and sulcus/scar (54.2%, 61.5%, 44.7%, 41.7% respectively), and Calcium Hydroxyapatite (CaHA)-based products were preferred for long-term paralysis (28.1%). CMC-based products were discontinued by 21.8% of participants, largely due to quick material resorption. 17.8% of participants discontinued HA-based products largely due to adverse events and 26.0% abandoned CaHA-based products mostly due to inflammatory properties causing vocal fold stiffness and material unpredictability. Over 30% of respondents reported wanting to reinitiate micronized alloderm Cymetra® as an available injectable.

CONCLUSION

Our survey demonstrated that there are significant variations in practice and preferences in regard to injectable material selection for VFI. As there is limited data on the direct material comparison, understanding the rationale behind these variations is crucial to guide new providers in material selection and provide information to patients undergoing these procedures.

LEVEL OF EVIDENCE

5 Laryngoscope, 133:1176-1183, 2023.

Autologous Lipoaugmentation Long-Term Clinical Outcomes: A Systematic Review

OBJECTIVES/HYPOTHESIS

Vocal fold (VF) lipoaugmentation can be employed to treat glottal insufficiency although variable data exist on its length of effectiveness. We aimed to review published long-term outcomes following lipoaugmentation across the literature and compile outcome data.

STUDY DESIGN

Systematic review.

METHODS

A systematic search in September 2020 of PubMed, MEDLINE, Cochrane Library, and Web of Science used the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify 128 relevant articles related to VF lipoaugmentation effectiveness duration. Primary search terms included the following: vocal cord, fat, lipo, and atrophy. Forty-eight full-text articles were reviewed and 31 were included in the final analysis. Primary endpoints included the following: duration of effectiveness per patient-reported outcome measures, objective findings, and additional procedures performed. In addition, fat harvest location and processing techniques were recorded.

FINDINGS

Thirty-one studies totaling 764 patients were included in the review. Indications for augmentation were VF paralysis (N = 690) and atrophy (N = 74). Fat was harvested from the abdominal region in 21 studies (529 patients), the thigh/abdomen in 5 studies (91 patients), and buccal/submental region in 2 studies (33 patients). Processing techniques and injectable volume varied. Across included studies, only 11 of 764 patients (1.4%) reported no improvement in voice and/or swallowing. Within the first year, 71 of 608 patients (11.7%) reported a regression toward baseline. Beyond 1 year and up to 8 years, 27 of 214 patients (12.6%) reported regression from initial improvement. Thirty-three patients underwent additional procedures.

CONCLUSION

Although improvements in voice and swallowing after lipoaugmentation taper over time, most patients experienced long-term benefit. Laryngoscope, 2021.

[Office-based phonosurgery]

Wesentliche und neue Impulse, die das Behandlungskonzept für ambulante phonochirurgische Eingriffe am unsedierten Patienten betreffen, stammen aktuell aus dem angloamerikanischen Sprachraum. Die dort etablierten „office-based procedures“ werden als eine Alternative zu vielen konventionellen operativen Larynxeingriffen in Vollnarkose propagiert. Maßgeblich für diese Entwicklung ist der Einsatz neuer endoskopischer Techniken in Kombination mit photoangiolytischen Laserverfahren (KTP-Laser und blauer Laser), die eine sichere und effiziente ambulante Phonochirurgie ermöglichen. Die Akzeptanz seitens der Patienten ist hoch, da ambulante Eingriffe als risikoärmer gelten. Ungeachtet der verbreiteten Euphorie fehlen weiterführende Studien, welche die medizinischen Entscheidungskriterien und das Sicherheitsmanagement bei dieser neuen ambulanten Ausrichtung der Kehlkopfchirurgie bewerten.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology

Introduction

Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies.

Recommendations

This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with.

Conclusions

The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

Medialization Laryngoplasty: A Review for Speech-Language Pathologists

Purpose The purpose of this study is to familiarize speech-language-pathologists with the current state of the science regarding medialization laryngoplasty in the treatment of voice disorders, with emphasis on current evidence-based practice, voice outcomes, and future directions for research. Method A literature review was performed in PubMed and Embase using the keywords vocal fold/cord and laryngoplasty, thyroplasty, augmentation, or laryngeal framework. Articles published between 2010 and 2020 were reviewed for data about clinical applications, technical approach, voice-related outcomes, and basic science or clinical innovations with the potential to improve patient care. A synthesis of data was performed from articles meeting the outlined search criteria. Conclusions As key members in the multidisciplinary care of voice disorders, speech-language pathologists need to be informed of current research in medialization laryngoplasty, a procedure commonly used for patients with glottic insufficiency. Advances in anesthetic technique, office-based procedures, and the development of materials with increased bio-tolerability over the past decade have led to innovations in treatment and improved patient outcomes. Recent applications of computational and bioengineering approaches have the potential to provide new directions in the refinement of currently available techniques and the improvement of patient-based treatment outcomes.

European white paper: oropharyngeal dysphagia in head and neck cancer

PURPOSE

To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe.

METHODS

Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion.

RESULTS

Twenty-four sections on HNC-specific OD topics.

CONCLUSION

This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.

Safety of in-office laryngology procedures

PURPOSE OF REVIEW

A wide range of diagnostic and therapeutic laryngology procedures are currently performed in an office setting. In-office laryngology procedures (IOLP) are increasingly seen as standard-of-care, and while generally considered safe, high-quality evidence supporting the latter statement is lacking. This review aims to summarize recent literature regarding the safety of IOLP.

RECENT FINDINGS

There is a paucity of guidelines and standardized protocols for IOLP. To date, there is one available safety protocol specific to in-office laser procedures. Haemodynamic changes during IOLP have been documented and the significance of these changes continues to be unclear. Therefore, monitoring of vital signs is recommended. Continuing antithrombotic therapy during IOLP also appears safe, and this decision may be left to surgeon discretion. A protocol for management of antithrombotic therapy prior to in-office laser procedures is available. Actual serum lidocaine levels following topical application of mixed lidocaine preparations falls well below reported toxic levels but persists for longer than previously reported.

SUMMARY

IOLP are safer that suspension laryngoscopy under general anaesthetic. Although complication rates of IOLP are low, patient characteristics and potential complications of both the procedure and of topical anaesthetic use must be considered. One must be prepared and equipped to deal with these potential complications.