Perception and duration of pain after office-based vocal fold injection augmentation

Distraction Therapies for Office-Based Otolaryngology Procedures Performed on the Upper Airway

OBJECTIVE

To assess the effectiveness of auditory and visual distraction interventions on patient discomfort, pain and anxiety during office-based otolaryngologic upper airway procedures.

DATA SOURCES

Literature searches were done through Cochrane Central Register of Controlled Trials, Lilacs, MEDLINE, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature.

REVIEW METHODS

The protocol was registered in PROSPERO on August 17th 2022, under Registration number CRD42020204354.

RESULTS

We identified 138 records; two randomised controlled trials using virtual reality as a distraction technique in adults and one in children were included. All studies had some concerns regarding risk of bias. In adults, anxiety was lower in the virtual reality group than in the standard of care, (mean difference -16.72, 95% CI -27.19 to -6.24, p = 0.002, I 2 = 0%). There was no difference in procedure related pain between groups, (mean difference -0.28, 95% CI -1.24 to 0.68, p = 0.57, I 2 = 10%). There was no difference in satisfaction between groups (standardised mean difference 0.18, 95% CI -0.22 to 0.58, p = 0.37, I 2 = 0%). Only one Paediatric study was included hence no meta-analysis was done. Anxiety and pain were lower and satisfaction was higher in the group using virtual reality.

CONCLUSIONS

The use of virtual reality distraction in addition to standard analgesia during office-based otolaryngology upper airway procedures reduced anxiety in adults. It did not decrease pain or increase the level of patient satisfaction. In the paediatric population, there is a reported benefit for procedural anxiety, pain and satisfaction.

Preprocedural Paracetamol Reduces Pain Scores in Patients Undergoing in-Office Laryngeal Procedures

OBJECTIVE

To investigate the utility of preprocedural paracetamol on reducing pain scores post office-based laryngeal procedures.

STUDY DESIGN

Prospective, controlled before-after comparative study.

SETTING

Controlled prospective before-after study.

METHODS

A retrospective analysis was performed of 100 patients who underwent office-based laryngeal procedures without preprocedural analgesia at our center to establish a control group. Age, sex, procedure type, and amount of substance used were documented as well as postprocedural pain score. Pain scores were recorded every 5 minutes for 30 minutes following office-based laryngeal procedures. A prospective arm of this study was then performed in which every patient undergoing office-based laryngeal procedures at our center between September 2019 and December 2020 was administered 1000 mg of paracetamol prior to their procedure. The postprocedure pain scores of the 2 groups were then compared.

RESULTS

A hundred patients were included in the retrospective arm and 75 patients were included in the prospective arm, receiving 1000 mg of paracetamol a median of 45 (interquartile range: 30-53) minutes prior to their procedure. The 2 groups were matched for age, sex, and type of laryngeal procedure. Both nonanalgesia and analgesia groups demonstrated a similar proportion of patients who experienced any pain (47% and 48%, respectively) postprocedurally. The prospective arm of this study however reported a statistically significant reduction in the magnitude of their pain scores at all points postprocedurally (P = .005).

CONCLUSION

Paracetamol preprocedurally reduces the severity of pain in office-based laryngeal procedures and would be a useful consideration for patients who are likely to experience significant postprocedural pain.

LEVEL OF EVIDENCE

Level 3.

Analgesia in Transcutaneous Laryngeal Botulinum Toxin Injections: A Randomized Crossover Trial

OBJECTIVES

There is an absence of data in the literature regarding methods to improve the patient experience during the performance of awake in-office laryngeal injections. This study sought to evaluate whether the use of local anesthetic or a vibrating instrument decreased overall pain experienced by patients with laryngeal dystonia, frequently referred to as spasmodic dysphonia (SD), undergoing transcervical botulinum toxin injections.

METHODS

This was an unblinded, prospective randomized control trial with a crossover design where each patient received transcutaneous transcricothyroid injection of botulinum toxin with alternating use of no anesthesia, local anesthesia (2% lidocaine in 1:100,000 epinephrine), and vibrating instrument in three consecutive laryngeal injections to treat adductor SD. Patients were randomized to the order they received these treatments. Patients measured pain on a 0-10 visual analogue scale (VAS) and selected their preferred technique after receiving all three analgesic modalities.

RESULTS

Thirty-two patients completed the study. There was no statistically significant difference in pain between the three analgesic techniques (p = 0.38). The most preferred analgesic technique was the vibrating wand (44% (14/32)). Lidocaine was the second most preferred (37% (12/32)) and 19% (6/32) of patients preferred nothing. When combining the wand and nothing groups, 63% of patients preferred one of these two methods (95% exact CI: 44%-79%).

CONCLUSION

There was no statistically significant difference in median pain experienced by patients during laryngeal botulinum toxin injection between these different analgesic modalities. More than half of the patients selected a preference for a technique that did not include lidocaine. This data supports individualization of analgesia during transcutaneous laryngeal injections.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:2277-2281, 2024.

Assessment of Postoperative Pain and Opioid Consumption Following Laryngeal Surgery: A Pilot Study

The epidemic of opioid use in the United States has been declared a national public health crisis due to the rapid increase in drug overdose mortality. Physician overprescribing has been identified as one of many contributing factors, with most patients receiving excess opioid pain medication. Furthermore, there is a significant correlation between prescribed opioid dosage and mortality. Postoperative pain is a well-recognized clinical problem, but little has been done to advance or standardize pain management protocols. The purpose of this study was to determine the expected postoperative pain severity and quantity of opioid analgesic required for adequate pain management after laryngeal surgery.

METHODS

Adult voice center patients who had recently undergone laryngeal surgery were included in this retrospective review. Tylenol #3 had been prescribed for all patients for pain management and they had been instructed to take additional over-the-counter acetaminophen as needed. In the senior author's (RTS) practice, patients are asked routinely to report pain severity and analgesic use during postoperative visits. All patients who had this information available were included in the cohort. Opioid medication consumed, over-the-counter medication consumed, and pain level (scale of 0-10 with 10 being most severe) were analyzed over the first week postoperatively.

RESULTS

There were 43 patients (19 male, 24 female) included in the retrospective cohort (average age = 46.8 ± 18.6, range = 18-82). Procedures performed included vocal fold mass excision (48.8%), type I thyroplasty (27.9%), laser vaporization of vascular lesions (11.6%), laser stenosis resection (9.3%), and VF medialization injection with abdominal fat harvest (7.0%). Overall, voice surgery patients reported mild to moderate pain (2.1-4.7 out of 10). An average of 13.2 ± 2.8 T3 tablets were prescribed for pain management (range = 10-20), and no patient required more T3 tablets than the number provided. Sixteen patients (37.2%) supplemented or substituted their T3 medication for it with OTC acetaminophen. No patients used non-steroidal anti-inflammatory drugs (NSAIDs) for supplemental pain management. Consumption of both T3 pain medication (r = 0.444) and OTC acetaminophen (r = 0.274) was correlated significantly with postoperative pain severity (P < 0.001). When stratified by type of surgical procedure performed, one-way ANOVA (F = 2.749, P = 0.043) and post-hoc Games-Howell test revealed that the patients who underwent type I thyroplasty reported a significantly higher (P = 0.041) pain severity score than patients who underwent vocal fold mass excision (4.7 versus 2.1, respectively). No significant differences in pain severity existed between other procedures (P > 0.05). There were no significant differences between type of procedure performed for number of T3 tablets prescribed, number of T3 tablets taken, or number of OTC tablets taken (P > 0.05). Younger age was correlated significantly with a higher number of OTC tablets consumed (r = -0.316, P = 0.039). Women consumed more OTC pain medications than men.

CONCLUSIONS

Most patients in this study reported mild to moderate postoperative pain. Adequate pain management was achieved using less pain medication tablets than the number prescribed. Type I thyroplasty was associated with more severe pain than other surgeries. Women used more OTC pain medications than men with no significant difference in reported pain level.

Spasmodic Dysphonia Patients' Perception of Pain with Botulinum Toxin Injections

OBJECTIVES

To evaluate spasmodic dysphonia patients' perception of pain associated with laryngeal botulinum toxin (BTX) injections and to determine factors associated with higher pain scores relative to other included patients.

METHODS

Prospective cohort study. Adult patients with adductor spasmodic dysphonia that presented to a tertiary laryngology practice for BTX injections were recruited from March to July 2022. Patients completed the visual analog scale (VAS) pre-procedure to quantify predicted pain. Ten minutes post-procedure they completed VAS and the short form McGill Pain Questionnaire (SF-MPQ). Factors that may affect pain were extracted from charts. Descriptive statistics, univariate, and multivariate analyses were conducted (alpha = 0.05).

RESULTS

One hundred and nineteen patients were included (63 ± 14 yo, 26% Male). SF-MPQ reported mild pain (4.12 ± 4.05 out of 45) with a pain intensity of none to mild (0.70 ± 0.89 out of 5). Bilateral injections yielded significantly higher SF-MPQ scores (5.19 ± 4.66) than unilateral injections (3.30 ± 3.30) (p = 0.012). There was a significant VAS reduction from pre 28.9 ± 24.6 mm (out of 10 mm) to post 24.5 ± 22.3 (p < 0.001). On multiple regression analyses, receiving a bilateral injection significantly (p < 0.05) contributed to a model that predicted higher pre-VAS (p = 0.013). Bilateral injections (p < 0.05) and higher VHI-10 (p < 0.05) contributed to a model that predicted higher total SF-MPQ (p = 0.001) and affective SF-MPQ (p = 0.001) scores. Not being a professional voice user (PVU) significantly (p < 0.05) contributed to a model that predicted higher post-VAS (p = 0.008) scores.

CONCLUSIONS

BTX injections were well tolerated with low pain scores. Factors associated with higher relative predicted or experienced pain included bilateral versus unilateral injection, PVU status, and higher VHI-10.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:240-246, 2024.

Pain Experience and Tolerance of Awake In-Office Upper Airway Procedures: Influencing Factors

OBJECTIVES/HYPOTHESIS

Awake, unsedated in-office upper airway procedures are performed frequently and have high completion rates, yet less is known about the patients' pain experience and potentially influencing factors. It is also unclear if patients' pain experiences become worse with repeated procedures. We identified procedure- and patient-related factors that might influence procedural completion and pain scores.

STUDY DESIGN

Retrospective chart review.

METHODS

Pre-, intra-, and post-procedure pain scores were collected prospectively for awake unsedated upper airway procedures performed at a single institution over a 5-year period. Patient factors reviewed were demographics, body mass index, psychiatric and/or pain diagnosis, and related medications. Procedure factors reviewed were procedure type, route, side, and performance of the same procedure multiple times. Patients reported their pain level before, during, and after the procedure using a standard 0 to 10 scale. Maximum pain score change (PΔmax), or the difference between highest and lowest reported pain levels, was calculated. Descriptive and multivariate analyses were performed.

RESULTS

Procedure completion was 98.7% for 609 first time patients and 99.0% in 60 patients undergoing 292 repeat procedures. PΔmax did not covary with age, gender, or BMI. PΔmax covaried with pain and psychiatric conditions and associated medications. PΔmax was highest for injection medialization and lowest for tracheoscopy. PΔmax decreased over time for those undergoing multiple identical procedures.

CONCLUSIONS

Procedures were performed with a very high completion rate and low pain scores. Age, sex, and BMI did not affect pain experience. A combination of pain and psychiatric conditions did. Injection medialization had the highest PΔmax and tracheoscopy the lowest.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1580-E1588, 2021.

Laryngeal Electromyography-Guided Hyaluronic Acid Vocal Fold Injections for Glottic Insufficiency

OBJECTIVES

To assess voice outcomes using the novel technique of in-office laryngeal electromyography-guided vocal fold injections (LEVFI) with hyaluronic acid to treat glottal insufficiency. Secondary objectives included determining the complication/completion rates and if any factors were associated with improved voice outcomes.

METHODS

Retrospective review of patients who received their first LEVFI from August 2017 to December 2018. Three- and six-month voice outcomes were assessed. Outcomes included voice handicap index-10 (VHI-10), maximum phonation time (MPT), perceptual analysis of voice (GRBAS), fundamental frequency, and stroboscopy.

RESULTS

Of the 121 eligible patients (55.4% male, age 63.7 years), 94 (77.7%) had complete 3-month data and 59 (48.8%) had complete 6-month data. VHI-10 was significantly improved from 25.7 ± 7.5 to 20.9 ± 10.9 at 3 months (P < .001) and to 19.1 ± 11.5 at 6 months (P < .001). MPT improved from 6.2 ± 5.4 seconds to 9.4 ± 7.1 seconds at 3 months (P < .001) and to 11.3 ± 8.2 seconds at 6 months (P < .001). GRBAS was improved in 74.8% of patients ([65.2, 82.8] 95% CI) at 3 months and 80.8% ([69.9, 89.1]) 95% CI) at 6 months. Stroboscopy showed a glottic gap improvement in 74.8% of patients ([65.8, 82.4] 95% CI) at 3 months and in 80.3% ([65.9, 88.5] 95% CI) at 6 months. Fundamental frequency was unchanged, as expected. Multivariate analysis reported that no factors were associated with better voice outcomes. Overall, 177/181 (97.8%) injections were completed. There were no complications.

CONCLUSION

In-office LEVFI is an effective, novel technique to treat glottic insufficiency with improved voice outcomes, high completion rate, and no significant complications.

Patient Perception and Duration of Pain after Microdirect Laryngoscopy

OBJECTIVE

Postoperative pain is an important part of the patient's surgical experience. The objective was to evaluate patient perception and duration of pain after microdirect laryngoscopy (MDL).

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary care, academic center.

SUBJECTS AND METHODS

Adult patients undergoing MDL were administered the short-form McGill Pain Questionnaire (SF-MPQ) before surgery and on postoperative days (PODs) 1, 3, and 7. Demographic and clinical data were collected.

RESULTS

In total, 130 patients (mean age 52.6 years, 84 male) participated in the study. About 46.2% required analgesia on POD 1, but only 23.1% required opioids. Overall, mild levels of pain were reported on the SF-MPQ: sensory score, affective score, total score, present pain intensity (PPI), and visual analog scale (VAS). Patients reported a significant increase in pain on POD 1, with decreases in pain on PODs 3 and 7. Pain score returned to preoperative values for total score and affective score on POD 7 but remained significantly elevated for PPI, VAS, and sensory score. None of the following factors were associated with increased pain: age, sex, body mass index, Mallampati score, Cormack score, laryngoscope used, type of MDL, time under anesthesia, employment status, intubation, Voice Handicap Index 10, and chronic pain history.

CONCLUSION

Although mild levels of pain were reported after MDL, the pain persisted for up to 7 days. No demographic or clinical factors were found to be associated with increased pain. This study was one of the few prospective studies evaluating pain after MDL.

The Safety and Efficacy of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Laryngologic Surgery

OBJECTIVES

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is an intraoperative ventilatory technique that allows avoidance of tracheal intubation (TI) or jet ventilation (JV) in selected laryngologic surgical cases. Unimpeded access to all parts of the glottis may improve surgical precision, decrease operative time, and potentially improve patient outcomes. The objective of this prospective, randomized, patient-blinded, 2-arm parallel pilot trial was to investigate the safety and efficacy of THRIVE use for adult patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration.

METHODS

Twenty adult, American society of anesthesiology class 1-3 patients with body mass index (BMI) < 35 kg/m² were randomly assigned to either an experimental THRIVE group or active comparator conventional ventilation group (TI or supraglottic high-frequency JV [SHFJV]). Primary outcomes included intraoperative oxygenation, anesthesia awakening/extubation time, time to laryngoscopic suspension, number of intraoperative suspension adjustments, and operative time. Secondary patient outcomes including postanesthesia and functional patient recovery were investigated.

RESULTS

Compared to TI/SHFJV, THRIVE use was associated with significantly lower intraoperative oxygenation (SpO₂ 93.0 ± 5.6% vs. 98.7 ± 1.6%), shorter time to suspension (1.8 ± 1.1 minutes vs. 4.3 ± 2.1 minutes), fewer suspension adjustments (0.4 ± 0.5 vs. 1.7 ± 0.9), and lower postoperative pain scores on recovery room admission (1.3 ± 1.9 vs. 3.7 ± 2.9) and discharge (0.9 ± 1.3 vs. 2.7 ± 1.8). The study was underpowered to detect other possible outcome differences.

CONCLUSION

We confirm the safe intraoperative oxygenation profile of THRIVE for selected patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration. THRIVE facilitated surgical exposure and improved early patient recovery, suggesting a potential economic benefit for outpatient laryngologic procedures. The results of this exploratory study provide a framework for designing future adequately powered THRIVE trials.

TRIAL REGISTER

ClinicalTrials.gov (NCT03091179).

LEVEL OF EVIDENCE

II Laryngoscope, 2020.

Assessment and Treatment of Pain during In-Office Otolaryngology Procedures: A Systematic Review

OBJECTIVE

To qualitatively assess practices of periprocedural pain assessment and control and to evaluate the effectiveness of interventions for pain during in-office procedures reported in the otolaryngology literature through a systematic review.

DATA SOURCES

PubMed, CINAHL, and Web of Science searches from inception to 2018.

REVIEW METHODS

English-language studies reporting qualitative or quantitative data for periprocedural pain assessment in adult patients undergoing in-office otolaryngology procedures were included. Risk of bias was assessed via the Cochrane Risk of Bias or Cochrane Risk of Bias in Non-Randomized Studies of Interventions tools as appropriate. Two reviewers screened all articles. Bias was assessed by 3 reviewers.

RESULTS

Eighty-six studies describing 32 types of procedures met inclusion criteria. Study quality and risk of bias ranged from good to serious but did not affect assessed outcomes. Validated methods of pain assessment were used by only 45% of studies. The most commonly used pain assessment was patient tolerance, or ability to simply complete a procedure. Only 5.8% of studies elicited patients' baseline pain levels prior to procedures, and a qualitative assessment of pain was done in merely 3.5%. Eleven unique pain control regimens were described in the literature, with 8% of studies failing to report method of pain control.

CONCLUSION

Many reports of measures and management of pain for in-office procedures exist but few employ validated measures, few are standardized, and current data do not support any specific pain control measures over others. Significant opportunity remains to investigate methods for improving patient pain and tolerance of in-office procedures.

Speech disorders in Parkinson's disease: pathophysiology, medical management and surgical approaches

The prevalence of speech disorders among individuals with Parkinson's disease (PD) has been reported to be as high as 89%. Speech impairment in PD results from a combination of motor and nonmotor deficits. The production of speech depends upon the coordination of various motor activities: respiration, phonation, articulation, resonance and prosody. A speech disorder is defined as impairment in any of its inter-related components. Despite the high prevalence of speech disorders in PD, only 3–4% receive speech treatment. Treatment modalities include pharmacological intervention, speech therapy, surgery, deep brain stimulation and vocal fold augmentation. Although management of Parkinsonian dysarthria is clinically challenging, speech treatment in PD should be part of a multidisciplinary approach to patient care in this disease.