In-Office Laryngeal Procedures in Awake Patients a Viable, and Often Preferable, Option

Dr. Postma and his colleagues perform in-office injections in patients with vocal cord paralysis to bulk up or change the position of the larynx. We can also inject the voice box with different types of augmenting fillers when the vocal folds don’t touch properly, he said.

With the aging population and an increasing number of people having problems with their voice because of vocal cord atrophy, voice therapy and vocal cord augmentation with injections may become more common, noted Dr. Johns.

Botox injections are useful for treating spasmodic dysphonia, whereas steroid injections can reduce vocal cord inflammation, added Dr. Postma.

Botox is also therapeutic for essential tremor that affects the larynx, noted Dr. Klein.

We’ll also inject cidofovir, an antiviral, in patients who have laryngeal papillomas, said Dr. Postma.

Several different methods can be used for administering injections, noted Dr. Klein. Some are given through the mouth or directly through the skin in the neck from various angles, he explained. Some require anesthetizing the patient’s nose to pass a flexible scope down to the vocal fold for visualization of the injection, he said.

Precautions and Contraindications

When conducting these diagnostic and therapeutic procedures, otolaryngologists should be aware that some patients won’t tolerate a scope, said Dr. Postma.

Some patients prefer to undergo full sedation, said Dr. Klein. Some people simply don’t tolerate scopes in their nose and mouth, he said.

Moreover, the patient’s nose may be too small for scope insertion, said Dr. Postma.

We recommend that otolaryngologists put patients who are singers under full sedation to treat lesions on their vocal folds, said Dr. Klein. Because of the nature of their vocal demands, we choose to put them to sleep to allow us to be more meticulous and to increase the chance of a good vocal outcome, he said.

One drawback of awake, in-office procedures is that physicians lose some precision, said Dr. Johns. Otolaryngologists should be aware that because the larynx is moving, the patient is awake and moving, and instrumentation is being passed through the flexible endoscope, that they don’t have the same precision as in the operating room, he explained. When precision is of utmost importance, then treatment in operating room makes sense, said Dr. Johns.

Otolaryngologists also have to be very careful using lasers for benign lesions that would otherwise require a precise resection under anesthesia, said Dr. Zeitels.

They should also be extremely careful while working with lasers on the internal surface of the vocal folds to avoid scarring, and should treat both vocal folds at the same time in the anterior commissure because it can result in webs and adhesions, Dr. Zeitels added.