Early versus late inpatient awake transcervical injection laryngoplasty after thoracic aortic repair

Time to Injection Laryngoplasty: A Quality Improvement Analysis

OBJECTIVE

Vocal fold (VF) augmentation injection laryngoplasty with hyaluronic acid is an effective and rapid office-based treatment for glottic insufficiency. Early injection laryngoplasty, defined as augmentation within the first three months, can decrease the risk of hospital readmission, aspiration pneumonia, and potentially reduce the need for future permanent surgical procedures such as Type 1 thyroplasty. This study aims to identify the time to injection for first-time laryngoplasty, describe the demographics of patients requiring VF medialization, and investigate causes for delays in treatment.

METHODS

This quality improvement assessment evaluated the time to first injection in patients requiring VF augmentation at the Voice and Dysphagia Laboratory at McGill University. This was a retrospective analysis of patients who received their initial hyaluronic acid injection for glottic insufficiency between April 2021 and March 2024. Patient demographics and reasons for delays were extracted from clinical records (ie, antithrombotic therapy, voice therapy attempts, anxiety, immunosuppressant medications, laryngeal infections, and cases of non-urgent or longstanding paralysis).

RESULTS

One hundred thirty-nine patients underwent VF augmentation. 48.9% were female and 51.1% male, with an average age of 66.2 years. The majority were treated for vocal cord paralysis (71.9%), followed by VF atrophy/presbylarynx (22.3%) and scarring (2.2%). Causes of paralysis included iatrogenic (49%), idiopathic (30%), neoplastic (18%), and others (3%). The mean time to injection for all patients was 21.7 days. Patients with glottic insufficiency causing aspiration or dysphagia were injected within 9.8 days (n = 56; VF paralysis n = 49, VF atrophy n = 7). Those with VF paralysis were injected within 13.5 days of initial consultation (n = 100) and those with VF paralysis and aspiration or dysphagia were injected within 10.1 days (n = 48). Patients with VF paralysis without delaying factors were augmented with injection in 1.44 days (n = 106). Thirty-three patients had delays in receiving their injection laryngoplasty and were injected at a mean of 80.0 days. Patients with delaying factors with aspiration or dysphagia were injected within 34.9 days (n = 16).

CONCLUSIONS

Our institution successfully achieves early injection in the majority of patients, with injections administered within two days of diagnosis when no "delaying factors" are present. Our main delaying factor was antithrombotic therapy use.

Prevention and Management of Recurrent Laryngeal Nerve Palsy in Minimally Invasive Esophagectomy: Current Status and Future Perspectives

Recurrent laryngeal nerve palsy remains a significant complication following minimally invasive esophagectomy for esophageal cancer. Despite advancements in surgical techniques and lymphadenectomy precision, the incidence of recurrent laryngeal nerve palsy has not been improved. Recurrent laryngeal nerve palsy predominantly affects the left side and may lead to unilateral or bilateral vocal cord paralysis, resulting in hoarseness, dysphagia, and an increased risk of aspiration pneumonia. While most cases of recurrent laryngeal nerve palsy are temporary and resolve within 6 to 12 months, some patients may experience permanent nerve dysfunction, severely impacting their quality of life. Prevention strategies, such as nerve integrity monitoring, robotic-assisted minimally invasive esophagectomy, and advanced dissection techniques, aim to minimize nerve injury, though their effectiveness varies. The management of recurrent laryngeal nerve palsy includes voice and swallowing rehabilitation, reinnervation techniques, and, in severe cases, surgical interventions such as thyroplasty and intracordal injection. As recurrent laryngeal nerve palsy can lead to significant postoperative respiratory complications, a multidisciplinary approach involving surgical precision, early detection, and comprehensive rehabilitation is crucial to improving patient outcomes and minimizing long-term morbidity in minimally invasive esophagectomy. This review article aims to inform esophageal surgeons and other clinicians about strategies for the prevention and management of recurrent laryngeal nerve palsy in esophagectomy.

Timing of Intracordal Trafermin Injection in Patients With Vocal Fold Paralysis: Recommendations for a New Treatment Time Course

OBJECTIVE

To identify factors correlated with the effect of intracordal trafermin injection.

STUDY DESIGN

Retrospective cohort study.

METHODS

Herein, 177 patients who received an intracordal trafermin injection at the Tokyo Voice Center for vocal fold paralysis were included. Medical records of patients were retrospectively reviewed. Information regarding age, sex, date of trafermin injection, date of vocal fold paralysis onset, and voice data indices [maximum phonation time (MPT), pitch range (PR), mean flow rate (MFR), and Voice Handicap Index (VHI)] was extracted. The primary endpoint was the rate of improvement in the VHI, defined as the difference in the VHI values before and after the injection.

RESULTS

A total of 80 patients (49 men and 31 women; mean age, 61.6 years) were included. No correlations existed between the MPT (r = 0.05, P = 0.64), PR (r = 0.03, P = 0.77), or MFR (r = -0.09, P = 0.42) before injection and the rate of improvement in the VHI. Analyses of 74 cases with an interval of <1000 days between disease onset and injection revealed no correlation between the number of days from the onset to injection and the rate of improvement in the VHI. In 17 cases with an interval of <90 days, a moderate negative correlation existed between these parameters (r = -0.59, P < 0.01). In a univariate linear regression analysis, within 90 days, a 1-week delay in trafermin injection resulted in a 4.87 decrease in the VHI.

CONCLUSIONS

Intracordal trafermin injection may be an effective therapeutic strategy for severe vocal fold paralysis, with a particularly high efficacy when performed early after paralysis onset. In patients undergoing aortic surgery, intracordal trafermin injection post surgery and before extubation may prevent or reduce postoperative voice disorders caused by vocal fold paralysis due to recurrent nerve palsy and prevent postoperative pulmonary complications.

Early injection laryngoplasty for acute unilateral vocal fold paralysis after thoracic aortic surgery

OBJECTIVE

Unilateral vocal fold paralysis (UVFP) following open thoracic aortic surgery increases pulmonary complications and hospital stays. An intervention protocol with early injection laryngoplasty (IL) and swallowing maneuvers was developed for acute UVFP following thoracic aortic surgery. This study aimed to compare the incidence of complications and length of medical care between the non-VFP and the IL-UVFP group managed under this protocol.

METHODS

Patients who underwent open thoracic aortic surgery from March 2020 to February 2023 were included, excluding those with preoperative VFP or postoperative bilateral VFP. Under the protocol, patients with UVFP and incomplete glottic closure received IL and swallowing maneuvers within one week after diagnosis, while those without a glottic gap started a soft diet along with swallowing maneuvers. Postoperative complications, including reintubation, ICU re-transfer, pneumonia, stroke, delirium, wound infection, and bleeding, as well as hospital and ICU stay, were assessed.

RESULTS

Of the 355 patients included in the study, 51 (14.4%) developed postoperative UVFP, while 304 (85.6%) had normal VF function. In the UVFP group, 42 patients underwent IL, while 9 patients without a glottic gap did not undergo IL. The incidence of complications and length of medical care were analyzed in the non-VFP and the IL-UVFP groups. The IL-UVFP group had a longer median hospital stay compared to the non-VFP group (20.5 vs. 16.0 days), though this difference was not statistically significant (P = .0681). ICU stay (P = .5396) and ICU re-transfer rates (P = 1.00) were also comparable between the groups. There was no significant difference in the incidence of pneumonia between the IL-UVFP group (4.8%) and the non-VFP group (9.5%) (P = .4003). Additionally, no significant differences were observed in the incidence of stroke, delirium, wound infection, or bleeding between the groups. No IL-related complications were reported.

CONCLUSIONS

The protocol with early IL appears to help reduce complication rates in acute UVFP patients following thoracic aortic surgery to levels comparable to those in patients without VFP. This protocol could serve as a guideline for otolaryngologists in managing UVFP patients.

LEVEL OF EVIDENCE

2b/Individual cohort study.

Oral and Pharyngeal Dysphagia in Adults

Patients with oral and pharyngeal dysphagia have difficulty forming a cohesive bolus and/or transferring food from the mouth into the pharynx and esophagus to initiate the involuntary swallowing process. This may be accompanied by nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx. Abnormalities affecting the upper esophageal sphincter, pharynx, larynx, or tongue, in isolation or combination, result in oropharyngeal dysphagia affecting either or both transit and airway protection. These issues can be addressed with a combination of management of the underlying systemic disease, with surgical intervention or with swallow therapy.

Intractable Bleeding Following an Awake Bedside Injection Laryngoplasty in a Patient on KVAD ECMO

INTRODUCTION

Awake injection laryngoplasty (IL) is becoming increasingly utilized in the inpatient setting, especially as a therapeutic option for patients with vocal fold immobility immediately following cardiothoracic surgery. While prior studies consistently demonstrate complication rates below 3%, significant bleeding has not been reported as a major complication in any awake IL case series. The objective of this report is to highlight a case of intractable bleeding following awake inpatient bedside IL in a patient on KVAD (Koji Takeda Ventricular Assist Device) extracorporeal membrane oxygenation (ECMO).

METHODS

Case Report.

RESULTS

A 24-year-old female admitted to the cardiac ICU for asystole was placed on KVAD ECMO for heart failure of unknown etiology. She was extubated and listed for cardiac transplant. On postoperative day 14, she underwent a left vocal fold injection at bedside to treat fold paralysis with a large glottic gap causing her complete aphonia, dysphagia, and chronic aspiration. Seven hours post procedure, the patient had to be reintubated due to intractable bleeding. A direct laryngoscopy was performed at bedside and continuous trickle of blood from the injection site at the superior posterior lateral surface of the vocal fold was stopped using a combination of epi-pledgets and hemostatic matrix. The same procedure had to be performed again due to further bleeding 2 days later and permanent hemostasis was achieved. During the week post injection, the patient required transfusion of 5 units of pRBC's. One month later the patient underwent successful orthotopic heart transplantation and was transferred from the ICU to a stepdown unit, and then a rehabilitation unit. No further IL hemorrhage occurred.

CONCLUSION

Although a few studies have discussed the safety of IL in patients receiving anticoagulation, this case report demonstrates intractable bleeding requiring intubation and intervention to achieve hemostasis in a patient on KVAD ECMO. This report highlights the importance of weighing the risks and benefits of vocal fold injection in this patient population.

Demographic differences in the treatment of unilateral vocal fold paralysis

Objective

To determine the impact of patient demographics and social determinants of health on treatment pathways for unilateral vocal fold paralysis (UVFP) at a tertiary laryngology clinic.

Study design

Retrospective medical record review.

Methods

Patient demographics (age, gender, race, ethnicity, and insurance status) were extracted for adults diagnosed with UVFP between 2009 and 2019. Odds ratios for the associations between sociodemographic factors and UVFP treatment pathways were determined by chi-square analyses.

Results

A total of 1490 UVFP diagnoses were identified during the study period with the majority being female (58%), White (85%), non-Hispanic (97%), and publicly insured (54%). Five treatment pathways were identified: observation, injection laryngoplasty, voice therapy, laryngeal framework surgery/thyroplasty, and reinnervation surgery. There were 538 patients who underwent observation, 512 injection laryngoplasty, 366 voice therapy, 136 thyroplasty, and 26 laryngeal reinnervation surgery. Males were more likely to undergo injection laryngoplasty than females (OR 1.32; CI 1.08-1.61), whereas females were more likely to undergo voice therapy (OR 1.39; CI 1.09-1.76). Patients with public insurance (OR 1.48; CI 1.03-2.14) and Hispanics (OR 2.60; CI 1.18-5.72) were more likely to undergo thyroplasty. Patients who underwent reinnervation surgery were younger than those in other treatment pathways (median: 39.1 years vs. 50.7-56.1 years).

Conclusions

Gender, ethnicity, and insurance status were significantly associated with specific UVFP treatment pathways. Patients with public insurance were more likely to undergo surgical intervention than voice therapy. This data overall supports differences in care pathway utilization for UVFP based on social determinants of health.

Level of evidence

Level IV.

Oropharyngeal Dysphagia in Acute Cervical Spinal Cord Injury: A Literature Review

Dysphagia (swallowing impairment) is a frequent complication of cervical spinal cord injury (cSCI). Recently published national guidance in the UK on rehabilitation after traumatic injury confirmed that people with cSCI are at risk for dysphagia and require early evaluation while remaining nil by mouth [National Institute for Health and Care Excellence. Rehabilitation after traumatic injury (NG211), 2022, https://www.nice.org.uk/guidance/ng21]. While the pathogenesis and pathophysiology of dysphagia in cSCI remains unclear, numerous risk factors have been identified in the literature. This review aims to summarize the literature on the risk factors, presentation, assessment, and management of dysphagia in patients with cSCI. A bespoke approach to dysphagia management, that accounts for the multiple system impairment in cSCI, is presented; the overarching aim of which is to support effective management of dysphagia in patients with cSCI to prevent adverse clinical consequences.

Inpatient Type 1 Thyroplasty Versus Injection Laryngoplasty for Vocal Fold Movement Impairment After Extent type I and II Aortic Repair

IMPORTANCE

Vocal fold motion impairment (VFMI) due to neuronal injury is a known complication following thoracic aortic repair that can impair pulmonary toilet function and post-operative recovery.

OBJECTIVE

To demonstrate clinical outcomes of patients undergoing inpatient vocal fold medialization for VFMI after aortic surgery.

DESIGN

A 15-year retrospective chart review (2005-2019) of 259 patients with postoperative VFMI after thoracic aortic surgery registry was conducted. Data included demographics, surgery characteristics, laryngology exam, and postoperative clinical outcomes. Medialization procedures consisted of type 1 thyroplasty and injection laryngoplasty.

SETTING

Tertiary care hospital.

PARTICIPANTS

Two hundred and fifty-nine patients (median age 61, 71% male) with VFMI post-thoracic aortic repair met inclusion criteria; inpatient vocal fold medialization was performed for 203 (78%) patients. One hundred and twenty-six. (49%) received type 1 thyroplasty and 77 (30%) received injection laryngoplasty procedures at a median 7 days (IQR 5-8 days) from extubation.

MAIN OUTCOMES

Primary study outcome measurements consisted of median LOS, median ICU LOS, complications intra- and postoperatively, and pulmonary complications (post-medialization bronchoscopies, pneumonia, tracheostomy, etc.).

RESULTS

Post-medialization bronchoscopy rates were significantly lower in the medialization (n = 11) versus the non-medialization group (n = 8) (5% vs 14%, P = .02) and significantly higher in the injection laryngoplasty group (n = 77) versus thyroplasty group (n = 126) (10% vs 2%, P = .02). Further analysis revealed no significant difference in overall LOS and pulmonary complications between the techniques.

CONCLUSION

Inpatient thyroplasty and injection laryngoplasty are both effective vocal fold medialization techniques after extent I and II aortic repair. Thyroplasty may have a small pulmonary toilet advantage, as measured by need for post-medialization bronchoscopy, compared to injection laryngoplasty.

Swallowing and laryngeal complications in lung and heart transplantation: Etiologies and diagnosis

Despite continued surgical advancements in the field of cardiothoracic transplantation, post-operative complications remain a burden for the patient and the multidisciplinary team. Lesser-known complications including swallowing disorders (dysphagia), and voice disorders (dysphonia), are now being reported. Such disorders are known to be associated with increased morbidity and mortality in other medical populations, however their etiology amongst the heart and lung transplant populations has received little attention in the literature. This paper explores the potential mechanisms of oropharyngeal dysphagia and dysphonia following transplantation and discusses optimal modalities of diagnostic evaluation and management. A greater understanding of the implications of swallowing and laryngeal dysfunction in the heart and lung transplant populations is important to expedite early diagnosis and management in order to optimize patient outcomes, minimize allograft injury and improve quality of life.

Critical care management after open thoracoabdominal aortic aneurysm repair

Thoracoabdominal aortic aneurysm repair is technically demanding for the surgeon and physiologically demanding on the patient. As such, it requires diligent multidisciplinary perioperative care to maximize the likelihood of a successful outcome. In this article, we discuss key principles for managing patients after open thoracoabdominal aortic aneurysm repair, which we have learned over the course of performing more than 3500 of such procedures. These principles address patient handoff between the operating room and Intensive Care Unit, resuscitation, prevention and management of spinal cord deficits, and important neurological, respiratory, cardiovascular, renal, gastrointestinal, and hematological considerations. Understanding the expected postoperative course allows for earlier recognition of deviations from that course and increases the likelihood of successful rescue of patients from adverse outcomes. Achieving positive outcomes after thoracoabdominal aortic aneurysm repair requires attention to detail across the perioperative, intraoperative, and postoperative phases of care.

Managing Otolaryngologic Complications in Cardiothoracic Surgery

BACKGROUND

Cardiothoracic procedures are often lifesaving operations, and because of their complexity they are not without complications. Although major complications are often recognized and treated immediately, there are many less commonly identified complications that can and frequently should be addressed by otolaryngology colleagues during a patient's hospital course.

METHODS

This comprehensive review describes otolaryngologic complications of cardiac and thoracic surgery.

RESULTS

Dysphonia, dysphagia, stridor, tracheotomy hemorrhage, and pharyngeal tear are all complications of cardiothoracic procedures. Indications for treatment and treatment options are reviewed. The impact on quality of life and long-term morbidity is also discussed.

CONCLUSIONS

Otolaryngologic complications are common after cardiothoracic procedures. An otolaryngologist should be asked to evaluate a patient with dysphonia, dysphagia, or stridor while the patient is an inpatient. Patients experiencing persistent or nonacute problems should be referred to otolaryngologists to discuss more long-term interventions.

Injection laryngoplasty in infants with unilateral vocal cord paralysis: A survey of ASPO members

INTRODUCTION

Unilateral vocal cord paralysis (UVCP) in infants may be managed medically or surgically, with the latter including injection laryngoplasty (IL). However, there is limited information regarding injection laryngoplasty in infants. We therefore proposed a survey of American Society of Pediatric Otolaryngology (ASPO) members to elucidate current practices, outcomes, and complications.

METHODS

An online survey was distributed to all 548 ASPO members via email. The survey was closed for data analysis 2 months after initial distribution. Statistical analysis was deferred due to the primarily descriptive nature of the data and lack of comparative studies.

RESULTS

We received 113 responses for a response rate of 20.6%. Only 31% of the respondents (n = 36) reported performing IL in infants 12 months old or younger. The most commonly cited reasons for not injecting in this age group were preference for non-surgical management and concern for increased risk of airway obstruction. IL was most commonly performed to treat persistent aspiration despite attempts at medical management. The majority (66%) reported no complications, while the remainder noted stridor requiring intensive care unit observation. Re-intubation due to airway obstruction occurred in 6% (n = 2 of 33). Carboxymethylcellulose gel (Prolaryn Gel) was the most commonly used injectable material, but a variety of other materials were used as well. Two respondents noted they perform reinnervation procedures in children, but not in infants, as they require at least a 12 month period of observation for possible spontaneous recovery before considering the option.

DISCUSSION

There is limited data regarding management of UVCP in infants with IL, and considerable variation among those who do perform the procedure. While adverse events are rare, multi-institutional studies should be considered to help determine best practices.