Safety and cost-effectiveness of intra-office flexible videolaryngoscopy with transoral vocal fold injection in dysphagic patients

Voice Outcomes Following Serial Office-Based Steroid Injections and Voice Therapy for Vocal Fold Scar

OBJECTIVE

Previous studies indicate that certain voice outcomes can improve following a single office-based steroid injection with voice therapy for vocal fold scar. We evaluated voice outcomes after a series of three timed office-based steroid injections with voice therapy.

STUDY DESIGN

Retrospective case series with chart review.

SETTING

Academic medical center.

METHODS

We evaluated pre-and postprocedural patient-reported, perceptual, acoustic, aerodynamic, and videostroboscopic parameters. We evaluated 23 patients who underwent three office-based dexamethasone injections into the superficial lamina propria one month apart. All patients pursued voice therapy.

RESULTS

Voice Handicap Index (n = 19; P= .030) decreased after injection series. Total GRBAS score (grade, roughness, breathiness, asthenia, strain) decreased (n = 23; P = 0.001). Dysphonia severity index score improved (n = 20; P = 0.041). Phonation threshold pressure did not decrease significantly (n = 22; P = 0.536). Videostroboscopic parameters of vocal fold edge (P = 0.023), right mucosal wave (P = 0.023) improved or normalized after injection series. Glottic closure (P = 0.134) did not improve.

CONCLUSIONS

Series of three office-based steroid injections combined with voice therapy for vocal fold scar does not appear to provide further benefit than one injection. Despite lack of improvements of PTP and other parameters, injection series is likewise unlikely to worsen dysphonia. A partially negative study provides value in investigation of less invasive treatment alternatives for a disorder that is challenging to treat. Future studies exploring effects of voice therapy alone without other intervention and consideration of sham injection versus steroid injection are warranted.

Comparison of Short and Long-Term Results after Injection Laryngoplasty with Radiesse® Voice and Thyroplasty Type I in Unilateral Vocal Fold Palsy

OBJECTIVES

Unilateral vocal fold palsy independently of etiology results in glottic insufficiency leading to unfavorable short or long-term impact on voice quality. Our aim was to evaluate the effect of injection laryngoplasty using Radiesse® Voice and thyroplasty type I on glottic closure, voice quality and aerodynamics by comparing preoperative, short- and long-term results.

MATERIALS AND METHODS

Data of 32 consent patients were reviewed between 2012 and 2023. All patients underwent either injection laryngoplasty (14 patients) or thyroplasty type I (18 patients) under local anesthesia. Maximum phonation time, glottic closure based on videolaryngostroboscopy, VHI-30 values and GRBAS scale were recorded prior, short-term (3 month) and long-term (12 months) after procedures for statistical comparison. Friedman test, Mann-Whitney test and Wilcoxon signed rank tests were used for statistical analysis.

RESULTS

In injection laryngoplasty group, we found significant improvement in maximum phonation time (p = 0.002), grade of hoarseness (p = 0.002) and breathiness (p = 0.000) when comparing results before and short-term after procedure. In thyroplasty type I group we saw significant improvement of maximum phonation time (p = 0.000), glottic insufficiency (p = 0.000), all three VHI-30 components (p = 0.000), as well as grade of hoarseness, breathiness (both p = 0.000) and roughness (p = 0.011) of GRBAS scale when comparing voice outcome before and short-term after procedure. There was no significant difference in voice outcome results neither between short and long-term results nor between the two groups in any parameter.

CONCLUSION

These results demonstrate both short and long-term efficiency of injection laryngoplasty and thyroplasty type I in the improvement of voice quality and glottic closure.

Aspiration prevention surgeries: a review

BACKGROUND

Severe dysphagia can cause intractable pneumonia and lead to life-threatening conditions. Intractable aspiration can occur despite medical management for aspiration prevention. Surgical intervention is indicated for intractable aspiration to prevent potentially life-threatening complications. Since the 1970s, several surgical treatments to prevent aspiration have been reported, and various aspiration prevention surgeries have been introduced, but little is known about them or their benefits. This is a review of the types of aspiration prevention surgery, with the aim of increasing aspiration prevention surgery awareness and their clinical outcomes among medical professionals, which will guide the choices of aspiration prevention surgeries for patients with intractable aspiration.

MAIN BODY

Aspiration prevention surgeries can be categorized into three according to their approaches: removal of the larynx, altering the structure of the trachea, and closure of the larynx. Aspiration prevention surgeries to remove the larynx include total and central-part laryngectomy. Aspiration prevention surgeries to alter the structure of the trachea include tracheoesophageal diversion, laryngotracheal separation, and the tracheal flap method. Surgeries to close the larynx can be divided into supraglottic laryngeal closure, glottic laryngeal closure, and subglottic laryngeal closure. Aspiration prevention surgeries prevent aspiration and increase oral intake in 50-80% of patients. Most patients lose vocal function after aspiration prevention surgeries; however, some patients who have undergone total laryngectomy or laryngotracheal separation restored their speech function through tracheoesophageal puncture and use of voice prosthesis. Postoperative suture failure is frequent after epiglottic flap closure and total laryngectomy but rare after central-part laryngectomy, laryngotracheal separation, glottic closure, and subglottic closure. Furthermore, aspiration prevention surgeries improve the quality of life of patients and their caregivers by decreasing suctioning frequency.

CONCLUSIONS

In this review, we described the history and development of aspiration prevention surgeries. Medical professionals need to continually improve their knowledge and skills to facilitate appropriate aspiration prevention surgeries according to patient condition.

Fibreoptic laryngoscopic assessment of patients with hoarseness: A cross-sectional analysis

Background:

Hoarseness is a common clinical manifestation of laryngeal diseases. The cause of hoarseness may not always be a simple inflammatory disease, but it can be from other serious life-threatening conditions such as laryngeal cancer, for which a delay in diagnosis of such condition may compromise treatment, resulting in poor prognosis and a decreased survival rate. Against this background, we evaluated the causes of hoarseness using fibreoptic laryngoscopy in our environment.

Materials and Methods:

This was a cross-sectional study of patients with hoarseness attending ENT clinic of our institution. Ethical clearance and consent were obtained. A questionnaire was used to collect relevant clinical data, fibreoptic laryngoscopy was carried out, and the data was analysed using the Statistical Products and Service Solution version 20.0.

Results:

The study recruited 90 patients with hoarseness. The age of the patients ranged between 18 and 70 years with a mean of 40.1 ± 14.8 years. There were 51 (56.7%) males and 39 (43.3%) females. About 46 (51.2%) of the patients had intermittent hoarseness, whereas 44 (48.8%) had persistent hoarseness. Most of the patients, 49 (54.4%), had hoarseness for less than 6 months before presentation. The fibreoptic laryngoscopic findings were non-specific laryngitis 49 (54.5%), laryngeal tumor 20 (22.2%), vocal cord polyp 7 (7.7%), laryngeal papilloma 6 (6.7%), vocal cord palsy 5 (5.6%), and others 3 (3.3%).

Conclusion:

Laryngeal tumour constituted a significant percentage of fibreoptic laryngoscopic findings in patients with hoarseness after nonspecific laryngitis. Therefore, fibreoptic laryngoscopy is recommended for all patients with hoarseness in order to detect sinister pathology early.

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).

Effectiveness of Injection Laryngoplasty for Aspiration in Acute Iatrogenic Vocal Fold Paralysis: A Systematic Review

OBJECTIVE/HYPOTHESIS

To review current evidence on effectiveness of injection laryngoplasty on aspiration outcomes in acute unilateral vocal fold paralysis.

STUDY DESIGN

Systematic review.

METHODS

A literature search was performed on MEDLINE, Embase, Scopus, and the Cochrane Library from inception of each database to May 2019. Inclusion criteria included case series, case-control studies, prospective cohort studies, and randomized controlled trials assessing the outcomes of early injection laryngoplasty on aspiration in unilateral vocal fold paralysis, in the acute setting. Only English articles with adult study populations were included. Two independent investigators screened all abstracts and manuscripts. Data on study design, patient demographics, interventions, and outcome measures were systematically extracted by both authors for included studies.

RESULTS

Fourteen case series studies comprising 582 patients were included. Results were not quantitatively synthesized due to the heterogeneity of outcome measures. Eleven studies reported that a majority (ranging 50%-100%) of patients in each respective study showed improvement in diet intake (progression from nil per os to oral) or Penetration-Aspiration Scale (PAS) scores after injection laryngoplasty. However, none of the investigations used a control group, and therefore, did not account for the possibility of improvement of function related to placebo or Hawthorne effects rather than attributed to intervention.

CONCLUSIONS

No robust evidence was found to support injection laryngoplasty as an effective measure to improve aspiration outcomes in acute iatrogenic vocal fold paralysis. Current practices rely on empirical observations and scarce expert opinions. Further prospective investigations with controlled objective measures are necessary to definitively demonstrate the effectiveness of IL for aspiration management. Laryngoscope, 2020.

The safety of in-office laryngologic procedures during active antithrombotic therapy

OBJECTIVES

To determine whether patients undergoing in-office laryngologic procedures on antithrombotic therapy are at increased risk for treatment-related complications.

METHODS

Patients were those who underwent at least one in-office laryngologic procedure with any of three fellowship-trained laryngologists. Procedures were identified by current procedural terminology (CPT) code and included biopsies, excisions, laser ablations, and injections (therapeutic and augmentative). Patients were divided into two groups based on the use of antithrombotic therapy at the time of their procedure. Retrospective chart review was performed to identify any complications, with an average follow-up of 186 days.

RESULTS

Five hundred-sixty-four unique individuals were identified with ages ranging from 18 to 93 years old and with a relatively even distribution between females (45%) and males (55%). They underwent 647 procedures in total, 310 of which were performed while on some form of antithrombotic therapy. Sixteen procedures were associated with complications either during or after the procedure. In comparing overall complication rates, there was no significant difference between non-antithrombotic (2.4%) and antithrombotic (3.3%) cohorts (OR 1.09, 95% CI [0.46-2.60], P = .8454).

CONCLUSIONS

In spite of known risks in other settings, antithrombotic agents do not appear to confer increased risk of treatment-related complications during in-office laryngologic procedures, obviating the need for cessation of therapy prior to these interventions.

LEVEL OF EVIDENCE

4.

Voice outcome after vocal fold injection augmentation with carboxymethyl cellulose versus calcium hydroxyapatite

BACKGROUND

Vocal fold injection augmentation is a recognised treatment modality for glottic insufficiency. Causes of glottal closure insufficiency include vocal fold paralysis, paresis, atrophy, sulcus vocalis, scarring and vocal fold deficiency after laryngeal surgery. A variety of materials exist for injection augmentation. This study aimed to compare voice improvement after injection augmentation between two injectable materials: carboxymethyl cellulose and calcium hydroxyapatite.

METHOD

This retrospective study included 66 consecutive patients with glottic insufficiency who underwent injection augmentation.

RESULTS

Among the patients who received their first injection augmentation with carboxymethyl cellulose and their second injection augmentation with calcium hydroxyapatite (n = 28), voice quality improved significantly after both injection augmentations. No significant differences were observed in any of the objective and subjective voice quality measurements examined following carboxymethyl cellulose and calcium hydroxyapatite injections.

CONCLUSION

Voice improvement after injection augmentation depends mainly on the improvement of glottic closure, rather than the injection material.

Office-based CO2 laser surgery for benign and premalignant laryngeal lesions

Objective

Patients with laryngeal pathology are often treated with CO₂ laser surgery, usually in the operating room under general anesthesia. Although office‐based laser surgery using several other laser types has been investigated, prospective studies on office‐based CO₂ laser surgery are scarce. Our goal was to investigate the feasibility of office‐based CO₂ laser surgery for benign and premalignant laryngeal pathology by analyzing completion rate, safety, effect on voice quality, and success rate (i.e., no residual or recurrent disease).

Methods

A prospective cohort study was performed of 30 consecutive procedures. Inclusion started in June 2016 and was completed in August 2018. Adult patients with clinically benign or premalignant laryngeal lesions who could not undergo transoral laser microsurgery in the operating room under general anesthesia were included. Reasons were either contraindications for general anesthesia, previously failed therapeutic laryngoscopy under general anesthesia, and preference of a procedure under topical anesthesia by the patient. The mean follow‐up was 9 months.

Results

Thirty procedures were performed in 27 patients (24 males) with an average age of 62 years. Twenty‐nine (97%) procedures were fully completed without complications. The mean preoperative Voice Handicap Index (VHI) score (VHI 44) significantly decreased 2 months (VHI 28, P = 0.032) and 6 months (VHI 14, P < 0.001) after the procedure. Almost two‐thirds of patients showed no residual or recurrent disease at their follow‐up visits.

Conclusion

Office‐based CO₂ laser surgery is a feasible and safe procedure that results in significant voice‐quality improvement. Almost two‐thirds of patients did not require further treatment.

Level of Evidence

2 Laryngoscope, 130:1503–1507, 2020

Office-based vs. operating room-performed laryngopharyngeal surgery: a review of cost differences

Purpose

Office-based transnasal flexible endoscopic surgery under topical anesthesia has recently been developed as an alternative for transoral laryngopharyngeal surgery under general anesthesia. The aim of this study was to evaluate differences in health care costs between the two surgical settings.

Methods

PubMed, EMBASE and Cochrane Library were searched for studies reporting on costs of laryngopharyngeal procedures that could either be performed in the office or operating room (i.e., laser surgery, biopsies, vocal fold injection, or hypopharyngeal or esophageal dilation). Quality assessment of the included references was performed.

Results

Of 2953 identified studies, 13 were included. Quality assessment revealed that methodology differed significantly among the included studies. All studies reported lower costs for procedures performed in the office compared to those performed in the operating room. The variation within reported hospital and physician charges was substantial.

Conclusion

Office-based laryngopharyngeal procedures under topical anesthesia result in lower costs compared to similar procedures performed under general anesthesia.

Electronic supplementary material

The online version of this article (10.1007/s00405-019-05617-z) contains supplementary material, which is available to authorized users.

Efficacy of trans-nasal fiberendoscopic injection laryngoplasty with centrifuged autologous fat in the treatment of glottic insufficiency due to unilateral vocal fold paralysis

SUMMARY

The objective of this work is to evaluate the safety, feasibility and efficacy of trans-nasal fiberendoscopic injection laryngoplasty (IL) with centrifuged autologous fat, performed under local anaesthesia, in the treatment of glottic insufficiency due to unilateral vocal fold paralysis (UVFP). It is a within-subject study with follow-up 1 week after phonosurgery and after 6 months. A total of 22 patients with chronic dysphonia caused by glottic insufficiency due to UVFP were enrolled. Each patient underwent trans-nasal IL with centrifuged autologous fat through flexible operative endoscope under local anaesthesia and was evaluated before and twice (1 week and 6 months) after phonosurgery, using a multidimensional set of investigations. The assessment protocol included videolaryngostroboscopy, perceptual evaluation of dysphonia, maximum phonation time and patient's self-assessment on voice-related quality of life (QOL) with the Voice Handicap Index-10 and the comparative self-assessment on vocal fatigue and voice quality pre-post treatment. Trans-nasal IL with centrifuged autologous fat was performed in all 22 patients and there were no complications in any case. Significant improvements in videolaryngostroboscopic findings, perceptual evaluation of dysphonia, maximum phonation time and QoL self-assessment were reported after 1 week and were maintained at 6 months. In one patient, the result after 6 months was not satisfactory and this patient then underwent a medialization laryngoplasty (thyroplasty type I) with satisfactory long-term results. In conclusion, trans-nasal fiberendoscopic IL with centrifuged autologous fat seems to be a safe, feasible and efficacious phonosurgical procedure for treatment of glottic insufficiency due to unilateral vocal fold paralysis.

Voice outcome measures after flexible endoscopic injection laryngoplasty

Objective

To report voice outcome measures after injection laryngoplasty using the transnasal or transoral flexible endoscopic technique.

Methods

A retrospective review of all patients who underwent flexible endoscopic injection laryngoplasty between June 2010 and August 2016 was carried out. Only those patients who had pre- and post-injection voice outcome measures recorded were included. Voice outcome measures recorded included perceptual voice evaluation using GRBAS, Voice Handicap Index-10 (VHI-10), maximum phonation time (MPT) and closed quotient (CQ) before and after treatment.

Results

Forty-six patients were identified, of which 32 had pre- and post-injection voice outcome measures recorded. There were 19 males and 13 females. The mean age was 56.97 years (range 20-86 years) and the most common indication was unilateral vocal fold paralysis. Thirteen patients had a transnasal flexible endoscopic injection), while 19 patients were injected transorally. Following injection laryngoplasty, there was significant improvement in the mean grade of dysphonia (2.81 vs. 1.22, P < 0.01, roughness (2.44 vs. 1.34, P < 0.01), breathiness (2.72 vs. 1.13, P < 0.01), asthenia (2.78 vs. 1.06, P < 0.01), and strain (2.44 vs. 1.19, P < 0.01), MPT (3.85 s vs. 9.85 s, P < 0.01) and mean CQ (0.19 vs. 0.46, P < 0.01). There was also a decrease in the mean VHI-10 score (33.31 vs. 7.94, P < 0.01).

Conclusion

s: Patients achieved significant improvement in both subjective and objective voice measures after flexible endoscopic injection laryngoplasty via the nasal or transoral route. Voice outcomes were comparable to those reported for other approaches. This technique provides an alternative approach for the management of patients with vocal fold paralysis or glottal insufficiency.

In-office laryngeal procedures (IOLP) in Canada: current safety practices and procedural care

BACKGROUND

The advent of chip tip technology combined with advanced endoscopy has revolutionized the field of laryngology in the past decade. Procedures such as transnasal esophagoscopy, site-specific steroid injections, injection laryngoplasty and laryngeal laser treatment can now be performed in the office setting under local anaesthesia. Although In-Office Laryngeal Procedures (IOLPs) have become standard-of-care in many American and several Canadian centers, there are no guidelines regulating the practice of these procedures. The goal of this report was to evaluate the current method of IOLP delivery in Canada.

METHODS

An electronic survey was dispersed to 22 practicing Canadian laryngologists to assess safety and procedural care measures undertaken when performing IOLP. The survey consisted of 37 questions divided into 6 categories; 1) Demographic data 2) Facilities 3) Staff/personnel 4) Patient screening/monitoring 5) Procedure and emergency equipment 6) Reporting of adverse events.

RESULTS

Data was collected for 16/22 laryngologists (72.7% response rate). Only 1 respondent did not perform IOLP. All performed injection augmentation laryngoplasty. Most performed laryngeal biopsies, intramuscular injection and/or electromyography guided injection for the treatment of spasmodic dysphonia and glottic/subglottic steroid injections. Only 4 respondents performed in-office KTP laser. Significant variation was found in procedural processes including intra procedural monitoring, anticoagulation screening, access to emergency equipment and documentation.

CONCLUSION

Our survey demonstrates that the delivery of IOLP in Canada varies considerably. The construct of IOLP practice guidelines based on the evidence with consistent documentation would promote safe, efficient and quality care for patient with voice disorders.

Injection laryngoplasty as miniinvasive office-based surgery in patients with unilateral vocal fold paralysis - voice quality outcomes

Introduction

Injection laryngoplasty (glottis augmentation) is the preferred method in surgical management of unilateral vocal fold paralysis (UVFP). Traditionally, these procedures are performed in the operating room. Nowadays, however, these procedures have moved into the office.

Aim

To evaluate the voice quality after transoral injection laryngoplasty under local anaesthesia in patients with unilateral vocal fold paralysis.

Material and methods

Fourteen subjects (5 women and 9 men) with unilateral vocal fold paresis (9 with right vocal fold paresis and 5 with left vocal fold paresis) were included in the study. The mean age of the group was 57.8 ±19.0 years (32–83 years). All of the injection laryngoplasties were performed transorally, under local anaesthesia. The injection material was calcium hydroxylapatite. Before and 1, 3 and 6 months after the procedure the following variables were evaluated: voice perception, videostroboscopy, acoustic analysis, aerodynamic evaluation, and the subjective rating of the voice quality by the patient.

Results

After injection laryngoplasty, complete glottal closure was achieved or there was a significant improvement in the glottal closure of each subject. We noted great improvement in the post-injection objective and subjective voice outcomes and patients reported improvement in the voice-related quality of life.

Conclusions

The transoral approach for injection laryngoplasty under local anaesthesia is an effective and safe way to treat incomplete glottal closure in patients with UVFP. The transoral approach is an efficient alternative to other surgical techniques used for vocal fold injection.

Cost analysis of injection laryngoplasty performed under local anaesthesia versus general anaesthesia: an Australian perspective

Objective:

To conduct a cost analysis of injection laryngoplasty performed in the operating theatre under local anaesthesia and general anaesthesia.

Methods:

The retrospective study included patients who had undergone injection laryngoplasty as day cases between July 2013 and March 2016. Cost data were obtained, along with patient demographics, anaesthetic details, type of injectant, American Society of Anesthesiologists score, length of stay, total operating theatre time and surgeon procedure time.

Results:

A total of 20 cases (general anaesthesia = 6, local anaesthesia = 14) were included in the cost analysis. The mean total cost under general anaesthesia (AU$2865.96 ± 756.29) was significantly higher than that under local anaesthesia (AU$1731.61 ± 290.29) (p < 0.001). The mean operating theatre time, surgeon procedure time and length of stay were all significantly lower under local anaesthesia compared to general anaesthesia. Time variables such as operating theatre time and length of stay were the most significant predictors of the total costs.

Conclusion:

Procedures performed under local anaesthesia in the operating theatre are associated with shorter operating theatre time and length of stay in the hospital, and provide significant cost savings. Further savings could be achieved if local anaesthesia procedures were performed in the office setting.

A comparative study of voice outcomes and complication rates in patients undergoing injection laryngoplasty performed under local versus general anaesthesia: an Adelaide voice specialist's experience

Objective:

To compare clinical outcomes and complication rates in patients undergoing injection laryngoplasty performed under local versus general anaesthesia.

Methods:

A retrospective review was conducted of patients who underwent injection laryngoplasty performed by a single laryngologist in a tertiary Australian laryngology centre, between February 2013 and December 2014. Patient demographics, anaesthetic modality and complications were recorded. Voice Handicap Index 10 and the Grade, Breathiness, Roughness, Asthenia, Strain scale were evaluated.

Results:

Thirty-four laryngoplasties were performed under general anaesthesia and 41 under local anaesthesia, with mean patient ages of 59.5 and 68.8 years, respectively. Voice Handicap Index 10 scores were significantly improved post-injection (p< 0.001), with no significant difference between general anaesthesia and local anaesthesia (p> 0.05). All aspects of the Grade, Breathiness, Roughness, Asthenia, Strain scale showed significant improvement post-injection, except asthenia. There were seven (9.3 per cent) minor complications (five in the general anaesthesia group, two in the local anaesthesia group), all managed conservatively.

Conclusion:

Injection laryngoplasties performed under general anaesthesia and local anaesthesia offer similar voice outcomes, with comparable complication rates. Hence, development of a management algorithm for injection laryngoplasties performed under local anaesthesia is recommended.

Therapeutic intervention in oropharyngeal dysphagia

Oropharyngeal dysphagia is a frequent consequence of several medical aetiologies, and even considered part of the normal ageing process. Early and accurate identification provides the opportunity for early implementation of dysphagia treatments. This Review describes the current state of the evidence related to dysphagia therapies - focusing on treatments most clinically utilized and of current interest to researchers. Despite successes in select studies, the level of evidence to support the efficacy of these treatments remains limited. Heterogeneity exists across studies in both how interventions are administered and how their therapeutic value is assessed, thereby making it difficult to establish external validation. Future work needs to address these caveats. Also, to be most efficacious, dysphagia therapies need to account for influences from pre-morbid patient characteristics as these factors have potential to increase the risk of dysphagia and the resulting complications of aspiration, malnutrition and psychological burden. Dysphagia therapies therefore need to incorporate the medical aetiology that is at its root, the resulting swallow physiology captured from comprehensive clinical and/or instrumental assessments, and the existing needs and supports of patients.

Voice Outcomes following a Single Office-Based Steroid Injection for Vocal Fold Scar

OBJECTIVE

Persistent dysphonia from vocal fold scar remains a clinical challenge, with current therapies providing inconsistent outcomes. We evaluated voice outcomes after a single office-based steroid injection.

STUDY DESIGN

Case series with chart review.

SETTING

Academic medical center.

SUBJECTS AND METHODS

This study was based on pre- and postoperative analysis of patient-reported, perceptual, acoustic, aerodynamic, and videostroboscopic parameters. The sample comprised 25 patients undergoing office-based dexamethasone injection into the superficial lamina propria for mild/moderate vocal fold scar. Average follow-up was 13.7 ± 4.4 weeks; patients completed 3.5 ± 2.3 sessions of voice therapy between assessments. Complete data sets were not available for each parameter; sample size is noted with results.

RESULTS

Voice handicap index (n = 24; P < .001) and glottal function index (n = 22; P < .001) decreased after injection. Total GRBAS score (grade, roughness, breathiness, asthenia, strain) decreased (n = 25; P < .001). Fundamental frequency range increased (n = 24; P = .024). Phonation threshold pressure decreased (n = 14; P = .017). Videostroboscopic parameters of vocal fold edge (P = .004), glottic closure (P = .003), and right mucosal wave (P = .016) improved after injection.

CONCLUSIONS

Office-based steroid injection combined with voice therapy for mild/moderate vocal fold scar is associated with improved patient-reported and functional voice measures. These findings provide preliminary support for this approach. Importantly, the procedure is low risk and can be performed in the office, thus offering a simple treatment alternative to patients with a disorder that has traditionally been difficult to manage. Prospective studies evaluating the effects of multiple injections are warranted.

Bedside Injection Medialization Laryngoplasty in Immediate Postoperative Patients

Objectives

The morbidity of glottic insufficiency resulting from unilateral vocal fold immobility may significantly compromise postoperative recovery in patients with decreased pulmonary reserve or inability to protect their airway. Injection medialization laryngoplasty is an effective means of treating glottic insufficiency due to unilateral vocal fold immobility. The purpose of this study is to present our experience with bedside transoral injection medialization laryngoplasty in the immediate postoperative period.

Study Design

Case series with chart review.

Setting

Academic tertiary care hospital.

Subjects and Methods

Patient demographics, clinical characteristics, procedural details, and short-term outcome measures of oral intake were recorded in a cohort of 68 patients over 5 years with unilateral vocal cord paralysis who underwent injection medialization as a bedside procedure in the immediate postoperative period.

Results

Mean time to injection was 8.2 days postoperatively. At the time of injection, 40 of 68 patients were nil per os. Seventy percent (28 of 40) had their diet advanced to adequate oral intake within 5 days of injection. Greater than half of the injections (36 of 68) were performed in the intensive care unit. No complications were noted, and all patients in this cohort were able to tolerate the bedside injection.

Conclusion

Bedside injection medialization laryngoplasty in the immediate postoperative period via the transoral approach can be performed in patients, even in the intensive care unit, while on anticoagulation, and may be of benefit for hospitalized patients with unilateral vocal fold immobility. Further studies quantifying improvement in voice and swallowing data are merited.

Transnasal injection laryngoplasty

OBJECTIVES

The objective of this study was to evaluate the role of transnasal fiber-optic injection laryngoplasty in the treatment of glottic insufficiency.

METHODS

Video recordings of 16 patients who underwent fiber-optic injection laryngoplasty for the treatment of glottic insufficiency were reviewed. Outcome measures included perceptual evaluation using the GRBAS (grading, roughness, breathiness, asthenia, straining) classification, laryngeal videostroboscopy, and frame-by-frame analysis to assess the extent, shape, and duration of glottic closure.

RESULTS

Nine patients were ultimately included in this study. Their mean age was 66.2 years, with 7 men and 2 women. The most common symptoms were dysphonia and aspiration, and the most common diagnosis was vocal fold paralysis. Patients underwent transnasal fiber-optic injection laryngoplasty with hyaluronic acid as a filling material (0.2-0.8 mL). The procedure was well tolerated by all patients, with improvement in the phonatory symptoms and aspiration in 66.66% and 50% of patients, respectively. There were significant decreases in the mean scores of all perceptual parameters (P<.05 for all). All subjects had glottal gap preoperatively that was closed completely in 66.66% and reduced to <2 mm in 33.33%. The mean closed quotient significantly increased from 0.10 to 0.51 (P<.05).

CONCLUSIONS

Transnasal fiber-optic injection laryngoplasty is a safe procedure well tolerated by patients with good results.

Systematic Review of the Quality of Economic Evaluations in the Otolaryngology Literature

Objective

To evaluate the quality of economic evaluations published in the otolaryngology—head and neck surgery literature, which will identify methodologic weaknesses that can be improved on in future studies. A secondary objective is to identify factors that may be associated with higher quality economic evaluations.

Data Sources

Ovid Medline (including PubMed), Embase, and the National Health Services Economic Evaluation databases.

Review Methods

A systematic search was performed of the aforementioned databases according to PRISMA guidelines. The search was performed using otolaryngology key terms combined with the term cost. A manual search of 36 otolaryngology journals was also performed. Included studies were graded using the Quality of Health Economics Studies instrument, a 16-item checklist providing a total quality score of 100.

Results

Fifty studies were identified, and the mean quality rating was 54.7/100 (SD = 30.9). The most commonly omitted methodology components were a lack of discussion of limitations and biases, failure to address the negative outcomes of examined interventions, and a lack of a robust sensitivity analysis. Higher quality economic evaluations were associated with a higher journal impact factor (correlation coefficient r = 0.62, P = .0001), having an author with a PhD in health economics ( r = 0.56, P = .0001), and having authors who have published prior economic evaluations ( r = 0.46, P = .001).

Conclusion

Results from this study have demonstrated that there are several methodological domains that can be improved on when publishing economic evaluations in the otolaryngology literature. Authors should follow recommended methodological and reporting guidelines to optimize the transparency and accuracy of the overall conclusions.

Characteristics of dysphagia in older patients evaluated at a tertiary center

OBJECTIVE

To determine laryngoscopic and videofluoroscopic swallowing study (VFSS) findings in geriatric patients with dysphagia; to evaluate management.

STUDY DESIGN

Retrospective chart review.

METHODS

Patients over 65 years old complaining of dysphagia, seen at a tertiary laryngology clinic, were included. Head and neck cancer and stroke patients were excluded. Demographics, laryngoscopic findings, swallowing studies, and treatment modalities were reviewed.

RESULTS

Sixty-five patients were included. Mean age was 75 years old (range = 66-97) with female predominance of 67.6%. Weight loss was seen in 9.2% of the patients. Whereas 52.3% of the patients complained of solid food dysphagia, 53.8% were choking on food. On laryngoscopy, 15.3% of the patients had pooling in the pyriform sinuses, 30.7% had glottic gap, 18.4% had vocal fold immobility, and 3% had hypomobility. VFSS showed that 38.4% of the patients had pharyngoesophageal dysphagia, 20% had oropharyngeal dysphagia, 20% had pharyngeal dysphagia, and 20% had a normal study. In addition, 41.5% of the patients showed laryngeal penetration and 18.4% showed aspiration. Surgical intervention was employed in 29.2% of the patients in the form of botulinum toxin injection, esophageal dilatation, cricopharyngeal myotomy, vocal fold injection, diverticulectomy, and percutaneous endoscopic gastrostomy. Whereas 21.5% of the patients received swallowing therapy, 61.5% underwent diet modification. As a result, 80% of the patients needed some type of treatment.

CONCLUSIONS

Swallowing problems in older patients are not uncommon. The clinician needs to be diligent to inquire about dysphagia because a large number of these patients will require treatment.

LEVEL OF EVIDENCE

4.

Office-based vocal fold injection with the laryngeal introducer technique

OBJECTIVES/HYPOTHESIS

There are numerous techniques for awake laryngeal injection, each with its limitations and technical challenges. We demonstrate a modification to the thyrohyoid approach for injection that stabilizes needle introduction and allows for consistent placement in a wide variety of larynges.

STUDY DESIGN

Retrospective review at a tertiary care institution.

METHODS

A retrospective review was performed of the charts for patients consecutively undergoing awake vocal fold injection laryngoplasty in 2013 for glottic insufficiency due to unilateral vocal fold paralysis, vocal fold atrophy, or sulcus vocalis using the laryngeal introducer technique. The consistency of needle placement, ease of technique, and patient tolerance was assessed. The technique utilizes a curved 1.5-inch 18-gauge needle as a laryngeal introducer through the thyroid notch. Laryngeal injection augmentation is then performed using a curved 3.5-inch 25-gauge spinal needle through the introducer.

RESULTS

Twenty-one patients were identified who underwent awake vocal fold injection laryngoplasty for glottic insufficiency. All 21 injections were successfully placed. Five of seven injections attempted by resident physicians were able to be completed without attending assistance. Patient experience data demonstrated good tolerance, with a preference for the awake procedure as compared to that performed under general anesthesia.

CONCLUSIONS

The laryngeal introducer technique is a novel way of performing awake laryngeal injections. It provides a high rate of success, the ability to be consistently performed by inexperienced clinicians, and is well tolerated by patients.

Safety and length of benefit of restylane for office-based injection medialization-a retrospective review of one institution's experience

OBJECTS

Restylane is a relatively new material being used for temporary vocal fold medialization. Few studies have evaluated the safety, complication rate, and length of benefit derived from Restylane injection medialization. We report on 64 patients who underwent office-based injection medialization with Restylane to establish the safety of and length of benefit from this material.

STUDY DESIGN

Retrospective review.

METHODS

Retrospective review of patients who underwent office-based injection medialization with Restylane during a 2-year period was performed.

RESULTS

Eighty-two injections in 64 patients were reviewed. Five total adverse events occurred (3.88%). The average length of benefit from injection medialization with Restylane was 12.2 weeks. No inflammatory or hypersensitivity reactions to Restylane occurred. A trend toward avoidance of permanent medialization was observed in patients injected <6 months from time of injury compared with patients injected >6 months after (P = 0.0511).

CONCLUSION

Restylane is a safe and effective temporary material for office-based injection medialization with an average length of benefit of 12.2 weeks. This represents the largest series to date using Restylane and no hypersensitivity or granulomatous reactions were observed. Our data showed a trend toward avoidance of permanent medialization in patients who were injected <6 months after nerve injury, which supports the findings of others.

Office-based injection laryngoplasty for the management of unilateral vocal fold paralysis

OBJECTIVE

Office-based injection laryngoplasty (OBIL) is a common method of addressing glottal insufficiency. This retrospective chart review identifies the demongraphics, laterality, technique, success rate, injectates, and complications of OBIL performed over a 3-year period at a single institution.

STUDY DESIGN

Retrospective chart review.

METHODS

All OBILs performed for the management of UVFP by the senior author over 3 years (2007-2009) were identified from billing records. The age, gender, laterality, underlying disease process, augmentation material, route of injection, and complications were recorded.

RESULTS

Eighty-two OBILs were attempted on 57 patients. The most common route of access was transoral (85.6%). All OBILs were able to be completed. Injectates used were hyaluronic acid derivatives (57.3%), calcium hydroxyapatite (16%), and Cymmetra (16.5%). Three complications (3.7%) occurred. Thirty percent of patients ultimately elected for thyroplasty or ansa reinnervation, 22% found their condition to self-resolve, 14% died, and 25% were lost to follow-up.

CONCLUSIONS

Using a variety of approaches, OBIL is possible in almost all patients. The single surgeon transoral route using a rigid angled telescope and curved injection needle was the most commonly used approach. Multiple injectates can be used and have good safety records. The final disposition of patients may be variable and warrants further investigation.

Prospective Evaluation of Office-Based Injection Laryngoplasty with Hyaluronic Acid Gel

Objectives:

The role of Juvederm Ultra Plus hyaluronic acid gel for use in injection laryngoplasty has not been well examined. The aim of this study was to prospectively assess the safety and clinical effectiveness of office-based injection laryngoplasty of Juvederm Ultra Plus gel in patients with glottic insufficiency.

Methods:

Thirty patients met the criteria for study inclusion and were treated with unsedated office-based injection laryngoplasty of Juvederm Ultra Plus gel over a 20-month period. The preinjection acoustic and aerodynamic measures, Voice Handicap Index, Glottal Function Index, and Dysphonia Severity Index were compared with values recorded at 1 and 4 months after injection.

Results:

Data for 27 patients were available for follow-up analysis at 1 month, and 12 patients' data were available at 4 months. Significant improvements, compared to preinjection levels (p < 0.02), were shown in all outcome measures at 1 and 4 months. One patient required intravenous steroid therapy for delayed glottic inflammation that resolved without permanent sequelae.

Conclusions:

The injection of Juvederm Ultra Plus gel is a relatively safe procedure that allows for short-term improvements in objective and subjective outcome measures of vocal function in patients with glottic insufficiency, provided the surgeon remains alert to the possibility of postprocedural injection site inflammation.

Clinical Practice Guideline: Hoarseness (Dysphonia)

Objective:

This guideline provides evidence-based recommendations on managing hoarseness (dysphonia), defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (QOL). Hoarseness affects nearly one-third of the population at some point in their lives. This guideline applies to all age groups evaluated in a setting where hoarseness would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with hoarseness.

Purpose:

The primary purpose of this guideline is to improve diagnostic accuracy for hoarseness (dysphonia), reduce inappropriate antibiotic use, reduce inappropriate steroid use, reduce inappropriate use of anti-reflux medications, reduce inappropriate use of radiographic imaging, and promote appropriate use of laryngoscopy, voice therapy, and surgery. In creating this guideline the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology–head and neck surgery, pediatrics, and consumers.

Results

The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness and 2) the clinician should advocate voice therapy for patients diagnosed with hoarseness that reduces voice-related QOL. The panel made recommendations that 1) the clinician should diagnose hoarseness (dysphonia) in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related QOL; 2) the clinician should assess the patient with hoarseness by history and/or physical examination for factors that modify management, such as one or more of the following: recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, radiation treatment to the neck, a history of tobacco abuse, and occupation as a singer or vocal performer; 3) the clinician should visualize the patient's larynx, or refer the patient to a clinician who can visualize the larynx, when hoarseness fails to resolve by a maximum of three months after onset, or irrespective of duration if a serious underlying cause is suspected; 4) the clinician should not obtain computed tomography or magnetic resonance imaging of the patient with a primary complaint of hoarseness prior to visualizing the larynx; 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease; 6) the clinician should not routinely prescribe oral corticosteroids to treat hoarseness; 7) the clinician should visualize the larynx before prescribing voice therapy and document/communicate the results to the speech-language pathologist; and 8) the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections for the treatment of hoarseness caused by adductor spasmodic dysphonia. The panel offered as options that 1) the clinician may perform laryngoscopy at any time in a patient with hoarseness, or may refer the patient to a clinician who can visualize the larynx; 2) the clinician may prescribe anti-reflux medication for patients with hoarseness and signs of chronic laryngitis; and 3) the clinician may educate/counsel patients with hoarseness about control/preventive measures.

Disclaimer:

This clinical practice guideline is not intended as a sole source of guidance in managing hoarseness (dysphonia). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

[Diagnosis and treatment of functional oropharyngeal dysphagia. Features of interest to the digestive surgeon]

Digestive surgeons should form part of the multidisciplinary team managing patients with oropharyngeal dysphagia. These patients can be diagnosed through clinical methods and complementary investigations such as videofluoroscopy and pharyngoesophageal manometry. These techniques also allow specific treatment to be selected. Up to one-third of patients with dysphagia suffer from malnutrition as a result of alterations in food bolus transport. Furthermore, up to two-thirds show alterations in swallowing safety (penetrations and aspirations, especially when swallowing liquids), as well as a high risk of respiratory infections and aspiration pneumonia. Increasing food bolus viscosity to 3500-4000 mPas (pudding viscosity) improves the effectiveness of swallowing and reduces the risk of aspirations. Botulinic toxin injection in the upper esophageal sphincter is indicated in patients with spasticity of neuromuscular origin. Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum and is also indicated in patients with alterations in the upper esophageal sphincter and preserved oropharyngeal motor response.