1. Videostroboscopy and laryngeal electromyography (EMG) can be used to determine the etiology of an immobile vocal fold in a patient with hoarseness after aortic aneurysm repair. 2. The difference between vocal fold medialization injection and intrachordal injection is that medialization injects material lateral to the vocalis muscle while intrachordal injection injects material just deep to the lamina propria to eliminate soft tissue defects. 3. Materials available for unilateral vocal fold medialization by injection include Teflon, human micronized alloderm, autologous fat, gelfoam, collagen, and hyaluronic acid formulations; alloderm

1. COCLIA Laryngology: PHONOSURGERY Samuel Ostrower January 14, 2008

2. Recurrent Laryngeal Nerve

4. Cricoarytenoid Joint

5. Intrinsic Musculature

6. Intrinsic Musculature

7. 1. A patient is referred from your favorite thoracic surgeon for hoarseness after aortic aneurysm repair. On exam, you find an immobile vocal fold. How can you determine the etiology?

8. Patient Evaluation Subjective assessment Phonatory function tasks Acoustic parameters Phonatory airflow Videostroboscopy Electromyography (EMG)

9. Videostroboscopy Illusion of slow motion created using a strobe light to illuminate the vocal folds at different points of different vibration cycles Evaluates: Glottic closure Symmetry Undersurface of vocal fold edges Stiffness, scar, submucosal injury Relative depth of tumor invasion Mucosal wave Vocal fold vibration patterns/amplitude Mucosal pliability

10. Laryngeal Electromyography (EMG) Only test available for evaluating integrity of laryngeal motor unit. Voluntary action potentials, fibrillation potentials, electrical silence Percutaneous or transoral placement of concentric bipolar needles Thyroarytenoid m. Posterior cricoarytenoid m. Cricothyroid m.

11. 2. Vocal fold injectional medialization Vs. Intrachordal injection. What is the difference?

13. Medialization vs Intrachordal Injection Vocal fold medialization injection Material injected lateral to vocalis m. in paraglottic space Vocal fold intrachordal injection Material is injected superficially, just deep to lamina propria, avoiding Reinke’s space Used for elimination of soft tissue defects

14. 3. Unilateral vocal fold medialization by injection – what materials are available? Indications and advantages?

15. Injection Materials Teflon (Polytef) Human micronized alloderm (Cymetra) Autologous fat Gelfoam Collagen Hydroxyapatite Hyaluronic acid formulations/Hylan B (Hylaform)

16. Teflon Paste (Polytef ® ) Permanent, non-reabsorbable material Viscous Poor vibratory/phonatory results Must be injected laterally Migration, extrusion, progressive inflammatory response Granuloma formation

17. Human Micronized Dermis/AlloDerm (Cymetra ® ) Most commonly used injectable Excellent phonatory results Low viscosity Temporary (effects last 6-12 months) Acellular, non-antigenic material causing minimal inflammatory response

18. Autologous Fat No inflammatory response Excellent phonatory results Requires additional incision Viscous, requiring Bruening syringe

19. Bovine Collagen Effective for management of vocal fold paralysis, sulcus vocalis and soft tissue deficits Temporary material Low viscosity Delayed hypersensitivity possible Skin testing recommended May lead to inflammatory changes leading to increased vocal fold stiffness, but unlikely permanent sequelae

20. Cross-Linked Hyaluronic Acid Gel (Hylaform ® ) Temporary Low viscosity Good phonatory results

21. Calcium Hydroxyapatite Gel (Radiance FN ® ) Permanent, non-reabsorbable material Phonatory results less well studied Relatively large particles not taken up by macrophages (no granuloma formation)

22. 4. Discuss the management of Teflon granulomas.

23. Teflon Granuloma Foreign body giant cell reaction Variable onset May occur between 4 months and 18 years following injection Therapeutic options

24. Teflon Granuloma Therapeutic Options Endoscopic with superior fold wedge resection/suction technique (Dedo, 1992) Midline thyrotomy/”hemilaryngectomy” technique (Russell, et al. 1995) Endoscopic with CO2 laser and superior VF microflap reconstruction (Ossoff, et al. 2003)

25. Lateral Laryngotomy Lateral laryngotomy (Netterville, 1998) Allows full granuloma excision with preservation of uninvolved lamina propria Sternothyroid muscle flap or silastic implant medializes remaining vocal fold after excision to optimize voice production

26. 5. Describe transcutaneous vs. laryngoscopic injection in vocal fold medialization

27. Transcutaneous Injection Thyroplasy Lateral approach Through thyroid ala at level of vocal fold (midway between thyroid notch and inferior margin of ala) Local anesthesia Direct visualization using flexible laryngoscopy

28. Transcutaneous Injection Thyroplasy Anterior approach Through cricothyroid membrane Local anesthesia Direct visualization using flexible laryngoscopy

29. Transcutaneous Injection Thyroplasy Luer Lock 1-cc syringe with 1-inch, 23-gauge needle Injection placed just anterior and lateral to vocal process on a plane level with lower border of medial edge of VF Use 0.5 – 1cc of Cymetra ®

30. Laryngoscopic Injection Thyroplasty Patients who do not tolerate flexible fiberoptic exam with percutaneous approach Used during ablative procedures when RLN or vagus sacrifice anticipated Performed under general anesthesia with spontaneous ventilation, apnea or jet ventilation

31. 6. Discuss the management of overinjection during vocal fold medialization

32. Overinjection Teflon overinjection Immediate mucosal incision and suctioning of excess material Delayed removal is problematic due to migration, scar and granuloma

33. 7. Medialization thyroplasty–indications, advantages. Otolaryngol Head Neck Surg 1997;116:349

34. Type I Thyroplasty Term coined by Isshiki in the 1970’s External medialization technique Immediate & reversible results Improves both voice & aspiration Local anesthesia

35. Indications Procedure of choice for the paralyzed vocal fold when recovery unlikely Vocal fold bowing from aging or cricothyroid joint fixation Sulcus vocalis Soft tissue defects from excision of pathologic tissue

36. Timing of Surgery Otolaryngol Head Neck Surg 1997; 116:349-54

37. Medialization Thyroplasty Materials Silastic Carved Prefabricated (Montgomery) Hydroxyapatite VoCom Gore-Tex Composed of Teflon

38. Surgical Technique

39. Surgical Technique

40. Surgical Technique

41. Surgical Technique

42. Surgical Technique

43. 9. Goal of Arytenoid Adduction. Indications

44. Arytenoid Adduction (AA) Surgical therapeutic option for correction of significant glottal incompetence in patients with laryngeal paralysis Mimics lateral cricoarytenoid m. to rotate the arytenoid vocal process medially Correct for asymmetries in vertical height

45. 10. Would you perform an arytenoid adduction without medialization procedure? Otolaryngol Head Neck Surg 2003;129:305-310

46. Arytenoid adduction combined with medialization thyroplasty: an evidence-based review ( Otolaryngol Head Neck Surg 2003;129:305-310) 219 articles Majority of articles discussed the benefits of MT or AA as a single intervention Only 3 articles directly evaluated the voice outcomes of MT plus AA versus MT alone There was no clear benefit in subjective or objective outcomes for AA plus MT

47. 11. How do you do an arytenoid adduction?

48. Arytenoid Adduction Technique

49. 12. What is the success of reinnervation procedures?

50. Reinnervation Techniques Neuromuscular pedicle (NMP) Ansa cervicalis-to-recurrent laryngeal nerve (ansa-RLN) anastomosis

51. Neuromuscular Pedicle Technique

52. Ansa Cervicalis-to-Recurrent Laryngeal Nerve (ansa-RLN) Anastomosis Technique

53. 13. Bilateral vocal fold paralysis in midline position. Patient refuses tracheostomy. What other surgical options can you offer? Ann Otol Rhinol Laryngol 1991; 100:717

54. Bilateral Vocal Fold Paralysis - Surgical Options Arytenoidectomy Arytenoidopexy Cordotomy Cordopexy Nerve-muscle transposition