Dr. Simpson said that injection laryngoplasty in clinic is the preferred technique in almost all cases, but that patients with significant medical co-morbidities may be better served by undergoing injection under local anesthesia in the operating room or in an endoscopy suite. That way, blood pressure, EKG and oximetry can be monitored during the procedure, which is more important in these patients because of significant fluctuation in these parameters during the procedure. He said his preferred method when performing injection laryngoplasty while the patient is awake is peroral but added, “I think everybody has their pet way of doing these.” Dr. Johns added that while the peroral approach gives more control, many patients don’t tolerate it well and, “in my hands,” he said, percutaneous tends to be better tolerated.
Explore this issue:October 2012
In another case, a 56-year-old man presented with sudden hoarseness that had come on seven months prior, but he hadn’t sought care because he was caring for his wife, who had breast cancer. He had no other complaints except for mild solid food dysphagia at times. There was no clear trauma or event that might have brought on his symptoms.
On video, Dr. Johns noted left vocal fold paresis and said that during phonation there was reduced left false vocal fold squeeze. He said there also appeared to be a volume deficit on the left side.
Dr. Simpson said he takes his reviews of these kinds of cases very slowly. “The residents know I’ll torment them on this. I really want the exam perfectly straight—I think it’s easier to judge asymmetries when you have it pretty symmetrically on the screen,” he said. “I look at these for a while. I look in slow motion. I really put a lot of time into looking at these exams before I try to make a call.”
The panel’s consensus was that there had been some kind of neuropathic injury. But they agreed they didn’t have much to go on. “We don’t really understand the etiology,” Dr. Blumin said. Dr. Simpson added, “When you talk about things that haven’t changed in the last ten years, I don’t think we have any more information to figure out what’s causing this.”
Dr. Johns said he would do nothing in terms of work-up. He said he used to routinely order CT scans in these kinds of cases—patients with vocal fold paresis who still have a mobile vocal fold. But researchers at Emory reviewed the results of about 150 CT scans in such cases and found zero abnormalities.