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October 2012WASHINGTON—A group of vocal fold experts gathered here to talk about patient cases involving vocal fold paralysis and to reflect on what treating those thousands of patients has taught them. Meeting in a session at the 2012 Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, held Sept. 9–12, the experts highlighted a few main points affecting the way they approach cases, approaches that have been shaped over the last several years:
- Changing perceptions on the need for electromyography (EMG), with the test generally not considered necessary except in limited circumstances;
- The use of monitoring during in-office procedures while patients are awake, with most panelists saying they don’t use monitoring but keep it accessible if a patient has difficulty; and
- New preferences for injectable materials, with most of the panel saying their main choice is hyaluronic acid gel, although they don’t consider it to be head and shoulders above many others.
The panelists included moderator Albert Merati, MD, chief of the laryngology service in the department of otolaryngology-head and neck surgery at the University of Washington in Seattle; Joel Blumin, MD, chief of otolaryngology at the Medical College of Wisconsin, Milwaukee; Michael Johns, MD, associate professor of otolaryngology at Atlanta’s Emory University and director of the Emory Voice Center; and C. Blake Simpson, MD, professor and director of the University of Texas Voice Center in San Antonio.
Case 1
The panel first discussed a 41-year-old patient in the Seattle area who had had a thyroid lobectomy four months earlier for disease that turned out to be benign. One day, she woke up breathy and frustrated with the quality of her voice. The original surgeon was confident the nerve had been identified and left unharmed during the lobectomy.
The patient had “clear left vocal fold paralysis,” with some volume loss or atrophy on the left side, Dr. Johns said after watching footage. “This is a patient who has potentially recoverable vocal fold paralysis, provided the nerve was left intact.” But, he added, “I’m not sure it’s going to change the management acutely.” Dr. Blumin agreed, saying it would only matter if the original surgeon actually said the nerve had been severed, in which case you would know recovery is less likely to occur spontaneously. Dr. Simpson added, “If it’s benign disease, they’ll very rarely say they think they cut the nerve or even injured the nerve.”
Dr. Blumin said he wouldn’t be likely to order EMG because it wouldn’t change the management: “She’s still four months [out] so there’s still a potential for spontaneous recovery.”
Dr. Johns said he used to do more diagnostic EMGs in cases like this, but he does fewer now. “It’s not a perfect test,” he said. Within the first two or three months of paralysis, an EMG wouldn’t change management, he added, and after about six months, recovery is not likely anyway. It’s that in-between period where an EMG may be valuable. “There’s that sweet spot in the two- to six-month period where maybe if there were unfavorable prognostic signs on a laryngeal EMG, we might consider early intervention with laryngeal framework surgery,” he said. But he said he’s stopped doing that—for the most part, anyway—because of recent studies showing that using a temporary injectable material leads to durable voice results in two-thirds of patients, regardless of recovery status.
Dr. Merati agreed. “An EMG may be helpful,” he said, “but just the act of relatively early injection laryngoplasty or medialization may reduce the rate of requiring permanent medialization later. I think that’s been a big change, particularly over the last couple years. I wonder if we’re all just sensitive now, just seeing the papers.” (Laryngoscope. 2010;120(11):2237-2240; Laryngoscope. 2012;122(10):2227-2233).
Dr. Johns said he would order a detailed voice assessment because that would be key in deciding whether to intervene at all. Dr. Simpson added: “I think it matters a lot what they do for a living,” and he’s more likely to intervene with a patient whose job involves using his voice a lot. He also cautioned against focusing too much on one vocal fold, because there could be subtle paresis on the other side, too. “That’s a mistake that I continue to learn from,” he said.
Dr. Blumin said that if the patient wanted treatment, he would see the patient with a speech pathologist, then come up with options. “This patient may do well with voice therapy alone,” he said.
Laryngoplasty
When doing an injection larygnoplasty—if that’s the course eventually taken—the panel said that, by and large, they perform the procedure without monitors. “In terms of precision of injection and fewer complications associated with the injection, there is decent evidence that doing these injections under general anesthesia, where you’ve got fine control, is more precise with fewer complications,” Dr. Johns said. “That being said, the complications of doing these awake is extremely low as well, about 5 percent.”
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.
Case 2
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.
Dr. Blumin said he would not normally do an EMG but might if the patient agrees. “I usually present that to the patient, saying that it’s sort of an academic exercise, and we would see if you have some kind of bilateral involvement,” he said. “However, I would treat what clinically seems to need to be treated, which appears to be the left side.”
Most of the panel said that they used to prefer Zyplast as the injection material, but it’s been off the market for two and a half years—removed by the manufacturer strictly for financial reasons, said Dr. Simpson. Dr. Merati said he “felt like I lost a friend that day.” Now, they tend to use Restylane, largely for its feeling of “cushioning” compared with some other agents.
Panel members agreed that the length of time a material will last after being injected is hard to predict from patient to patient, regardless of which material is used. “I’ve seen it happen variably with all these materials,” Dr. Johns said. “And I’ve tried them all, so I think they’re largely substitutable.”