Transcervical Vocal Fold Injection (In-Office)
Main Text
Table of Contents
Vocal fold injection (VFI) is a treatment modality applicable to various laryngeal diseases and is successfully used as an alternative to laryngeal framework surgery. The indications for in-office VFI include vocal fold paralysis, paresis, atrophy, and scarring along with their sequelae.1
This video is a detailed demonstration of office-based VFI in a patient with unilateral vocal fold paralysis (UVFP), which is the most common neurologic disorder affecting the larynx. It is secondary to damage to the recurrent laryngeal nerve, which usually results from cancer, trauma, or surgery. Although the majority of cases can be attributed to a known etiology, one-fourth of patients present without a clear precipitating event.2 UVFP presents with dysphonia, dyspnea, and dysphagia. The effects on voice and swallowing can have a significant negative impact on the patient's quality of life. Among the options of voice therapy, laser treatment, surgical intervention, and office-based VFI, the latter emerges as a treatment of choice in this particular patient, offering immediate results and higher cost-effectiveness compared to the surgical approach.3 The aim of this procedure in UVFP is "medialization" of the affected cord to improve voice quality by injecting a filler material into the depth of the affected vocal fold.
Careful patient selection is pivotal when choosing office-based VFI as a treatment option. An optimal candidate has minimal gag reflex, given that a hyper-responsive gag reflex may render the visualization with a flexible endoscope—and hence the procedure in itself—impossible. Additionally, it is necessary to have a reasonable threshold for pain, a minimal level of anxiety, and an ability to remain still for a duration of up to 30 minutes. Additionally, the patient must have a clear nasal airway to pass the flexible scope. Patients with severe head tremor may pose challenges during the examination. In-office VFI is performed under local anesthesia, and if adequate anesthesia is not achieved, the patient may experience severe discomfort, anxiety, elevated sensitivity, and is unlikely to be able to tolerate a procedure performed in office settings. Informing the patient of each upcoming step during the procedure may help ameliorate some of the anxiety.4
In-office VFI encompasses transcervical, so-called percutaneous (trans-cricothyroid membrane, trans-thyroid cartilage, and trans-thyrohyoid membrane), trans-nasal, and per-oral endoscopic approaches. Many materials have been used for injection, such as autologous fat, cadaveric dermis, methyl-cellulose, and hyaluronic acid; however, more evidence is needed to establish the ideal material. Moreover, every substance tends to induce some level of tissue reactivity. In the case of transient injectables, this reactivity is likely to disappear with the material gone over time. The greater the thickness of the soft tissue separating the injectable from the membranous vocal fold, the lower the likelihood of adverse effects on vocal fold vibration caused by either the injectable itself or the ensuing inflammatory response.1 In this clinical case, micronized particulate cadaveric human acellular dermis (Cymetra) was selected as the filler material.
The patient's preparation begins with the application of local anesthesia: tetracaine 2% spray is used to desensitize the nasal cavities. Subsequently, the patient is instructed to refrain from speaking, swallowing, and coughing, unless requested. The thyroid cartilage is palpated in the middle and traced downward until a dip and a firm ring of tissue are felt. These are the cricoid groove and the cricoid cartilage, respectively. The cricothyroid membrane is located immediately above the groove of the cricoid. With the patient in a sitting position and head straight, lidocaine solution is injected through the cricothyroid membrane, and verification of correct tracheal placement is ensured by aspirating air. The injection is made from a higher level, which allows the lidocaine to pass through the vocal folds and descend along the anatomical structures, enveloping the larynx. Before the injection, the patient is prepared for the experience, being informed that they may feel a pinch, followed by a brief period of coughing.
While waiting for the lidocaine to take effect, the practitioner takes the opportunity to prepare and ensure that all elements are ready for the subsequent steps. The compatibility of the 1.5-inch long 23-gauge needle with the Cymetra substance is confirmed. Normal saline is mixed with Cymetra in the syringe, which is manipulated back and forth to ensure an even and clump-free mixture. The final step involves removing air from the syringe by moving it back and forth, allowing air to re-enter, and eventually expelling all air.1
Next, a flexible laryngoscope is positioned in the left nostril. Given that the right side of the larynx is being addressed, the left nostril is chosen to provide an optimal view. In the trans-cricothyroid membrane approach, the slightly angled 23-gauge needle is inserted just below the lower edge of the thyroid cartilage, about 3–7 mm to the right of the midline. The needle is then moved upwards and sideways with gentle pressure. This motion helps ensure the needle is beneath the surface layer, preventing any accidental puncture of the mucosa. The patient is guided through vocalizations such as "Eee" with additional instructions to swallow, as the initial condition of the vocal folds are evaluated on the display. Next, the filler is injected, seen as an increase in the thickness of the fold on the monitor. The patient is then prompted once again to voice "Eee," illustrating the effect of the injection on vocal cord function. In case the injected material is distributed unevenly, resulting in an irregular vocal fold contour, the patient may be instructed to clear their throat or produce a sharp cough to help attain a more uniform distribution.
It is important not to overcorrect the paralyzed vocal fold and to avoid subglottic disposition of the filler material. The infiltration of the filler material should be stopped as soon as the vocal fold is at midline. The subglottic region should be inspected with the laryngoscope to avoid subglottic disposition. Moreover, in order to avoid extravasation of the filler material it is advised to insert the needle in “stair step” fashion: entering mucosa; moving the needle 1–2 mm lateral; pushing the needle in 1–3 mm further.6
Following the procedure, due to the effects of the anesthetic used during the intervention, the patient is advised to refrain from eating or drinking for two hours until full sensation returns to the larynx. However, the patient is allowed to talk after the procedure. The patient is monitored for a period of 15–30 minutes to ensure effective control of bleeding and absence of dyspnea.6
The use of VFI in awake patients without sedation has become increasingly popular, presenting a notable trend in recent years. VFI is recognized as a safe, effective, and clinically feasible treatment with a high success rate. This video serves as an invaluable resource for medical practitioners, highlighting the growing utilization of VFI. Medialization of the paralyzed vocal fold not only enhances vocal quality by restoring glottal competence but also contributes to improved swallowing function.5 The negligible complication rates associated with this procedure make it a compelling choice, comparable to surgery requiring general anesthesia. Notably, recent advancements in material engineering and digital imaging technology have elevated this method as an attractive alternative to traditional laryngeal framework surgery in carefully selected patients.1
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- Sielska-Badurek EM, Sobol M, Jędra K, Rzepakowska A, Osuch-Wójcikiewicz E, Niemczyk K. Injection laryngoplasty as miniinvasive office-based surgery in patients with unilateral vocal fold paralysis - voice quality outcomes. Wideochir Inne Tech Maloinwazyjne. 2017 Sep;12(3):277-284. doi:10.5114/wiitm.2017.68868.
- Korean Society of Laryngology; Phoniatrics and Logopedics Guideline Task Force; Ryu CH, Kwon TK, Kim H, Kim HS, Park IS, Woo JH, Lee SH, Lee SW, Lim JY, Kim ST, Jin SM, Choi SH. Guidelines for the management of unilateral vocal vold paralysis from the Korean Society of Laryngology, Phoniatrics and Logopedics. Clin Exp Otorhinolaryngol. 2020 Nov;13(4):340-360. doi:10.21053/ceo.2020.00409.
- Kaplan, SE, Siddiqui SH, Spiegel JR. Management of vocal fold paralysis II: role of injection medialization. Int J Head Neck Surg. 2022;12(4):161-165. doi:10.5005/jp-journals-10001-1516.
- Bar R, Mattei A, Haddad R, Giovanni A. Laryngeal office-based procedures: A safe approach. American journal of otolaryngology, 2023;45(2):104128. doi:10.1016/j.amjoto.2023.104128.
- Cates DJ, Venkatesan NN, Strong B, Kuhn MA, Belafsky PC. Effect of vocal fold medialization on dysphagia in patients with unilateral vocal fold immobility. Otolaryngol Head Neck Surg. 2016 Sep;155(3):454-7. doi:10.1177/0194599816645765.
- Modi VK. Vocal fold injection medialization laryngoplasty. Advances in oto-rhino-laryngology. 2012;73:90–94. doi:10.1159/000334448.
Cite this article
Cohen SM, Brown CS. Transcervical vocal fold injection (in-office). J Med Insight. 2024;2024(149). doi:10.24296/jomi/149.
Procedure Outline
Table of Contents
- Importance of Anesthesia
- Indications
- Evolution of Procedure
- Caveats/Pitfalls
- Patient Benefits from In-Office Procedure
- Patient Role in Ensuring Success
- Post-op Restrictions
- Alternatives
Transcription
CHAPTER 1
I’m Seth Cohen, Associate Professor in the Department of Surgeryin the Division of Head and Neck Surgery and Communications Scienceswithin the Duke Voice Care Center.I practice laryngology.
So anesthesia is really the key.So you can do this procedure and keeping the patient calm.So the way I do it, we use Avertin and tetracaine in the nose,to numb the nose, and then I'll use plain lidocaine without epinephrine.The way I usually like to do the procedure is through the cricothyroid membrane.So I will inject that plain lidocaine through the cricothyroid membrane,draw back and make sure I'm in the trachea by drawing back air.And then I’ll inject with the bevel pointed superiorly,so the lidocaine goes through the vocal foldsand then falls and bathes the larynx.And then I'll use a little lidocaine with epinephrine to just numb the skinand the area over the cricothyroid membrane.
So anybody who needs augmentation of their vocal foldsto help their problem, so unilateral vocal fold paralysis,unilateral vocal cord atrophy, or bilateral vocal cord atrophy,you can do both vocal folds at the same time in the office.It’s more convenient. It’s cheaper.You can get improvement the same day that you see the patient,and you can get some feedback,because the patient’s awake and talking to you while you do the injections.Obviously it depends on the patient tolerance,and it's a discussion that you have with the patient about options.I think anybody who has good anatomy, good tolerance,who's not too squeamish with needles,is a good candidate for the procedure.
When I first learned it,I guess I tried different ways of getting through the cartilage.But trying to go through the cartilage can be problematic,as the cartilage becomes ossified.I've tried various ways of numbing the patient including nebulizing lidocaine,and I find that just a little bit of lidocaine -I usually use one or two percent,2 cc without epinephrine into the airway and then,at the most a half a cc of 1% with epinephrine in the skin givesthe best anesthetic for me.
So certainly patient tolerance is one.Making sure you have good anesthesia.The anatomy is very important -so do you have good palpable landmarks?Do they have a really short neck where trying to get the angleto get the needle superiorly is important?I do put a bend on my needle,so that once you enter the cricothyroid membrane,you can then use the angle of the needle then to tryand get superiorly to the vocal fold.It’s good to be facile with other options as well,such as a transcartilaginous approachor going through the thyrohyoid space,if for some reason you're having difficulty getting inthrough the cricothyroid membrane.
He's a cardiac patient and he had an idiopathic paralysis.So we got a CT scan, which you have to do to in those casesto make sure that there's not a lesion involving the vagusor recurrent laryngeal nerve. He did not.So hopefully, there’s a good chance this won't return,but he was incredibly hoarse.Very breathy, and you know when you have a vocal fold paralysis,you affect your ability to swallow potentially,your ability to have a good cough, your ability to talk,and because you can’t do a good Valsalva,your energy level goes down.He had good, palpable landmarks.We talked about what would be involved with the office injection.He thought he could tolerate it.So he was a good candidate for the procedure.
One thing I should mention too is you need a partner.The way I like to do it uses theflexibility of the laryngoscope, and then you'remanaging the needle with the collagen.You know, I had the patient sit upright, close their mouth,and breathe in slowly through their nose, and try and relax.
Just because of the anesthetic, I limit them not to eat or drink for 2 hoursuntil all the sensation comes back in their larynx.But I do usually do let them talk, afterwards.I explain that the voice maybe worse before it gets better,because this is a temporizing measure,so I typically will over-inject with the collagenon purpose to get it to last as long as possible.
So for him, his vocal cord enclosure was pretty poor,so voice therapy really was not an option for him.Because it was idiopathic, and it was early in the onset,I would not proceed directly to a permanent laryngoplasty.So for him, I think the only other option was doing this in the operating room.Being on blood thinners and being a cardiac patient,there’s risks with general anesthesia, so I think overall,from a morbidity standpoint, this is certainly safer for the patient.And certainly I would be amenable to having that done in the officeversus having to be NPO after midnight, go to the operating room,and then have to recover from anesthetic.
CHAPTER 2
So I’m just going to - this is just some lidocaine, okay?Yep.And we’re going to inject into the cricothyroid spacewith the bevel pointed superiorly,so the medicine will go through the vocal cords and then fall down and numb -numb the area from the inside, okay?You’re going to feel a pinch, and then you will cough for a few seconds.Just hold really still and don't bump my arm.I draw back until I get air, and then brace my left handbecause he's going to coughand get that in as quickly as we can.[Patient coughs.]And there’s the cough, that’s mixing the lidocaine around everywhere.Yeah.And then this is just a bit more lidocaine thatwe’re just going to do in the skin, okay?And I always do the other part first so I don’t cause a huge bleb,and then have a hard time getting the lidocaine endolaryngealbecause that’s where we really need the lidocaine.Okay, and while that’s working I’m going to get everything mixed up, okay?
CHAPTER 3
And she’s already sprayed your nose.And I'm just mixing it up with some injectable saline.Do you have a certain amount that you use?I do - 1.7. Sometimes I try and cheat and do a tiny bit less,so about 1.6 sometimes.But if you make it too thick, it’s hard to inject the Cymetra through the needle.So you can’t get rid of too much of the saline.And then, because this can clump sometimes, what I dois I’ve already pulled the syringe back from 2 to 3 mLsand banged it around a little bit.
CHAPTER 4
And then you want to get the air - get the saline up flush with this connector,and this is the most important part,is I have to get saline to the plunger, so it doesn’t clump.So I do it really fast and keep the pressure on there.And now I’ve got plenty of saline down here, and then a few more little bangsto distribute that and then back and forth quickly,and now we don’t have any clumps. Now I just have to get the air out.So back and forth and then let the air come back into the 3 cc syringe,and then you just do that a few times,and then eventually all the air will come out.Okay, so now we have no more air, so we are ready to go.
CHAPTER 5
And then I take one of these 1.5-inch, 23-gauge needles.And make sure my Cymetra will go through.So I’m getting it out the end, and because I like to go throughthe cricothyroid space, sometimes it’s harder to go through the cartilage,and I’m going to put a bend on this.Make sure it’s still running. And then the angle we’re going to try and dois go laterally through the cricothyroid space,and then we have to drop our hand down pretty quickly.And sometimes, people with short necks,it’s hard to get that angle to get secure enough.So I find that that bend helps a little bit.And then we’re going to put the camera in the opposite nose.And since we’re doing the right side,we’ll try and go in the left nose to have a good view.And you’re comfortable? Yep.Okay. Do you want something behind your head?I’m all right. Okay.Just breathe.And we can see the blood from my injection.And we’ll just take a quick picture before.And say, "E." Say "Eee.""Eee." Try and hold that one more time.Can you swallow for me sir? Excellent.Good, and "Eee". "Eee."Try and hold it, "Eee." "Eee."
CHAPTER 6
Okay. All right, so nice, easy breathing now, okay?I’m going to see if I can slide in here.Okay.So I’m getting closer, but I’m still too inferior.Almost there. That's right, hang tight, you’re doing great.
CHAPTER 7
All right so I’m right in the vocal cord now. Hold really still.Okay.It’s getting really fat, and then we’ll take a picture again.And say, "Eee." "Eee."One more time, hold it out, "Eee." "Eee."Okay.All done.