There is no such thing as a “best” injectable material, he said. “The reason there are so many out there is because none of them have all the best characteristics.” Otolaryngologists should use the material they find to be most reliable in their hands. The goal of the given case also matters—in some, a temporary injectable is preferred; in others, a long-term result is the goal.
Explore This IssueNovember 2016
The setting for the injection, whether it is the office or the operating room, depends on the comfort and experience of the surgeon, patient anatomy, and tolerance of laryngoscopy, Dr. Francis said. When choosing an injection technique—transoral, transthyrohyoid, transcricothyroid, or transthyroid cartilage—patient anatomy and surgeon preference are major considerations. “The true vocal fold is not in the same position in every single patient by any means at all,” Dr. McWhorter said. There is variability in the level of the vocal fold relative to the top and bottom of the thyroid cartilage, which affects access, he added.
The advantages to performing the procedure in the operating room rather than in the office are that it is simpler to add more material if needed and that the surgeon has more control, which generally leads to more precision, Dr. McWhorter said. He also noted that the published literature suggests that outcomes and risks in intra-office when compared with intra-operative injections do not differ significantly.
Type 1 Thyroplasty
Adam Rubin, MD, director of the Lakeshore Professional Voice Center in St. Clair Shores, Mich., waits nearly a year after the onset of vocal fold paralysis to see how a patient progresses before performing type 1 thyroplasty. “It’s so easy to perform injection laryngoplasty and temporize people and help patients’ symptoms, so why not give a paralyzed vocal fold the best chance to regain mobility or for synkinesis?” he said.
The recipe for a good result is a combination of good anesthesia, a good patient (one who shows commitment to pre- and postoperative voice therapy, is well-informed, and can tolerate being awake for parts of the procedure), a good technique, and a good ear to assess the procedure’s effect.
Anesthesia, he said, should be chosen according to what the anesthesiologist is comfortable with, as long as the patient is just sleepy enough that she can be roused to use her voice at the necessary moments.
Dr. Rubin noted that Gore-Tex tends to make for a quicker procedure, is easier to add and withdraw, and doesn’t require carving an implant, but it can be easy to get some of the ribbon too high or too low. Silastic, he said, tends to be better for larger gaps.