POST-OPERATIVE LARYNGEAL COMPLICATIONS AFTER ENDOCRINE SURGERY

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1 POST-OPERATIVE LARYNGEAL COMPLICATIONS AFTER ENDOCRINE SURGERY Amy L. Rutt, D.O. Mayo Clinic Jacksonville, FL AOCOO-HNS Foundation 2015 MFMER slide-1

2 Etiology (n=280) (n=363) Overall Trends (literature review) Malignancy 24.7% 13% Surgical/Iatrogenic 23.9% 46.3% Idiopathic 19.6% 17.6% Nonsurgical Trauma 11.1% 2.2% Neurologic 7.9% 3.0% Intubation 7.5% 4.4% Thoracic aortic aneurysm 4.3% 0.6% Infectious % From Rosenthal LHS, Benninger MS, Deeb RH. Vocal fold immobility : a longitudinal analysis of etiology over 20 years. Laryngoscope 2007;117: MFMER slide-2

3 Ext.br. SLN RLN 2015 MFMER slide-3

4 Vocal fold paralysis Superior laryngeal nerve (SLN) Pitch control Recurrent laryngeal nerve (RLN) Vocal fold (VF) movement Adduction (closing) / abduction (opening) Unilateral Bilateral 2015 MFMER slide-4

difficulty) Dyspnea Bilateral (limited glottal gap)

5 Vocal fold paralysis Symptoms Unilateral (large glottal gap) Dysphonia (bad voice) Dysphagia (swallowing difficulty) Dyspnea Bilateral (limited glottal gap) Airway restriction, stridor Good voice, swallowing 2015 MFMER slide-5

6 Vocal fold paralysis - Prognosis VF paralysis can recover Complete or partial ~ 6 months Laryngeal electromyography (LEMG) Measures electrical activity of laryngeal muscles Diagnosis: paralysis vs. dislocation Prognosis for spontaneous recovery Shortens time to permanent treatment 2015 MFMER slide-6

7 Laryngeal electromyography 2015 MFMER slide-7

8 Traditional qualitative LEMG Class Spontaneous Activity Recruitment Individual Motor Unit Morphology Interpretatio n I Absent Normal Normal Normal II Absent Reduced Polyphasic units "Old injury"* III Present Reduced Polyphasic units "Equivocal" IV Present Absent Fibs, myokymia, etc. Denervation Positive predictive value (PPV): 80% Negative predictive value (NPV): 67-71% Myers. Operative Otolaryngology Head and Neck Surgery, Management of the Paralyzed Vocal Fold, 1997, p 382. Munin MC, Rosen CA, Zullo T. Arch Phys Med Rehabil 2003;84: Wang CC, Chang MH, Wang CP, Liu SA. Arch Otolaryngol Head Neck Surg 2008;134: MFMER slide-8

9 Synkinesis Misdirected re-innervation of the adductor and abductor laryngeal muscle nerve fibers 88% of specimens after nerve injury (animal studies) eee sniff sniff PPV increased from 67 to 76% NPV from 53 to 100% Statham MM, Rosen CA, Smith LJ, Munin MC. Laryngoscope 2010;120: MFMER slide-9

10 Quantitative LEMG Widely commercially available Common component in EMG of other body parts Mean turns analysis Change in signal direction at peak of MU signal Each successive turn separated by 100 µv Excludes low-amplitude peaks from noise and electrical interference Differentiate normal from acute vocal fold paralysis 400 mean turns/s Statham MM, Rosen CA, Nandedkar SD, Munin MC. Laryngoscope 2010;120: MFMER slide-10

11 Normal PPV Severe neuropathy Smith LJ, Rosen CA, Niyonkuru C, Munin MC. Laryngoscope 2012 Apr;122(4): MFMER slide-11

12 * Optimal LEMG Interpretation Qualitative Motor Unit Characteristics PPV = 100% NPV = 90% Accuracy = 91% Presence of Synkinesis * Quantitative Mean Turns Analysis 2015 MFMER slide-12

13 Vocal fold paralysis - Treatment (Voice therapy, swallow therapy) Surgical options Temporary VF injection 1, 2 Permanent VF injection Laryngeal framework surgery Laryngeal re-innervation Drug trials? 1 Yung KC, Likhterov I, Courey MS, Laryngoscope 2011;121(10): Young VN, Smith LJ, Rosen CA, accepted OtoHNS MFMER slide-13

14 VF injection - Locations BODY X 1 X 2 BODY = Superior arcuate line 2015 MFMER slide-14

15 VF Injection Material (Ideal) Biocompatible Safe from transmission of infectious disease Matched mechanical property to host location (viscosity) Stable (inert) Use a fine-gauge needle (24 g or smaller) Off the shelf (minimal prep) 2015 MFMER slide-15

16 VF Injection Material: Present Gelfoam Collagen Radiesse Voice Gel TM Hyaluronic acid Restylane,. Calcium hydroxylapatite (CaHA) Radiesse Voice TM Fascia (autologous/allogenic) Fat (autologous) 2015 MFMER slide-16

17 Gelfoam TM Gelatin Bovine gelatin Sterile powder (1 gm) Longest track-record of laryngeal injectables 30 years (1970s) #1 injectable, ABEA survey, 2004 (Merati) Bottom line Lasts 4 weeks Requires preparation 18g needle Poor vibratory properties Limited use today 2015 MFMER slide-17

Significant preparation required (hassle) Cosmoplast/Cosmoderm

18 Collagen-Based Injectables Cymetra Micronized cadaveric dermis Prion infection transmission risk? Significant preparation required (hassle) Cosmoplast/Cosmoderm Human engineered collagen No track record Bottom line Lasts 2-3 months 2015 MFMER slide-18

3%) Carboxymethylcellulose Cortisone, decadron Common food additive

19 Radiesse Voice Gel TM 3 Basic components Water (82.3%), Glycerin (14.5%) Carboxymethylcellulose (CMC 2.3%) Carboxymethylcellulose Cortisone, decadron Common food additive Gel carrier for Radiesse TM (CaHA) FDA approved for VF injection Bottom line Lasts 1-3 months 2015 MFMER slide-19

20 Hyaluronic Acid Glycosaminoglycan (polysaccharide) Found in dermis Low tissue reactivity Hypersensitivity 0.6% Bottom line Duration: 6-9 months? 2015 MFMER slide-20

Calcium Hydroxylapatite CaHA Long-term, successful solid implant in orthopedics and dentistry Radiesse Voice TM Spherules of calcium hydroxylapatite (CaHA) Suspended in

21 Calcium Hydroxylapatite CaHA Long-term, successful solid implant in orthopedics and dentistry Radiesse Voice TM Spherules of calcium hydroxylapatite (CaHA) Suspended in aqueous-based gel CMC, water, glycerin Voice gel component resorbs over-inject ~10% FDA approved for VF injection Inflammatory response? Bottom line Lasts 1-2 years 2015 MFMER slide-21

22 Lipoinjection Liposuction or open harvest Fat preparation Rinse fat, insulin? gauge needle Overinjection by 30-50% Unpredictable MAC or general anesthesia 2015 MFMER slide-22

23 Lipoinjection Pre-injection Post-injection 2015 MFMER slide-23

24 VF injection - Material Gelfoam Cymetra Radiesse Voice Gel Hyaluronic acid Gel CaHA (Radiesse Voice) ~ 1 month ~ 1-2 months* ~ 1-3 months* ~ 6-9 months?* ~ 1-2 years Fat ~ forever? * Temporary VF injection duration study: currently in progress 2015 MFMER slide-24

25 Which glottic injectable should I use? 2015 MFMER slide-25

26 VF injection techniques: What setting? General anesthesia Office Operating room Local/MAC 2015 MFMER slide-26

27 Where we have been Where are we going? Laryngologists 3 voice centers 5 year trends Number of patients Bedside Office OR Year 2015 MFMER slide-27

28 Comparison Office Co-morbidities Real time monitoring Well tolerated/preferred Young et al, Laryngoscope 2012 Costs 505% less Bove et al, Laryngoscope 2007 Efficacy/complications = to OR Sulica et al, Laryngoscope 2010 OR Co-morbidities Anatomy Anxiety Xanax Ativan Technical precision 2015 MFMER slide-28

29 Bilateral deep vocal fold augmentation 2015 MFMER slide-29

30 Vocal fold injection - OR Local/MAC Endoscopic General MSL Endoscopic 2015 MFMER slide-30

31 Vocal fold injection - OR 2015 MFMER slide-31

32 Laryngeal framework surgery Medialization laryngoplasty Implant placed into larynx to medialize VF Type I thyroplasty Isshiki 1974 Silastic Gore-Tex tm Arytenoid adduction Suture placed to re-position the VF Awake Intra-operative voice monitoring 2015 MFMER slide-32

33 Type I Thyroplasty AKA Medialization Laryngoplasty c Gold standard VFP expect improvement Implants Silastic Netterville/block VoCom Hydroxyapatite Gore-tex Titanium 2015 MFMER slide-33

34 Medialization Laryngoplasty Intra-op monitoring Localization 2015 MFMER slide-34

35 Medialization laryngoplasty 2015 MFMER slide-35

36 2015 MFMER slide-36

37 Pearls of ML Excellent window localization Implant placement Posterior (toward muscle process) Inferior (infraglottis) Anterior? Often not needed When done, very small amount of implant Slight over-correction to compensate for peri-op edema Decadron 8mg PO night before sx Decadron 10-20mg IV pre-op Inadvertent entry into airway stop. NO implant! 2015 MFMER slide-37

38 New Trends No drain, bone wax, glue No antibiotics Post-op steroids? 23 hr. obs? Same day sx: U/L, local 23 hr obs: B/L (atrophy/vfp + atrophy), not local 2015 MFMER slide-38

39 ML: pros / cons BENEFITS Improved glottic closure Intraoperative monitoring Adjustable Reversible COMPLICATIONS Implant migration Implant extrusion Implant misplacement Under/over-augmented Hematoma/edema airway compromise Need to revise 2015 MFMER slide-39

40 Arytenoid Adduction Indications Large posterior gap Unequal vocal fold levels Improve tone? Improves acoustical power and increases subglottic pressure 2015 MFMER slide-40

41 From Rosen CA and Simpson CB. Operative Techniques in Laryngology. Springer, MFMER slide-41

42 Arytenoid Adduction Complications Piriform sinus injury Over/Under correct Thyroid cartilage fx Basically All the time Never Sometimes Adds 2 hrs Increased risks Technically challenging 2015 MFMER slide-42

43 Vocal fold paresis Partial injury (weakness) of the RLN or SLN RLN Paresis VF is mobile VF strength is weak VF closure is incomplete Voice is weak and tires easily Frequently seen following recovery from VF paralysis 2015 MFMER slide-43

44 Vocal fold paresis - Treatment Similar to vocal fold paralysis Observation Voice therapy VF injection Thyroplasty 2015 MFMER slide-44

45 Bilateral vocal fold paralysis Poor airway May require tracheotomy Good voice Once permanent paralysis - treatment aimed to improve breathing Remove small portion of VF to increase size of breathing space Airway v. Voice 2015 MFMER slide-45

46 Bilateral VFP - Surgery 2015 MFMER slide-46

47 Management of VF paralysis LEMG provides prognostic information about nerve function recovery Unilateral VF paralysis Breathy voice Swallowing, cough impaired Bilateral VF paralysis Voice and swallowing good Airway compromised 2015 MFMER slide-47

48 Thank you MFMER slide-48

Glottal Incompetence: Management Pearls and Pitfalls

Glottal Incompetence: Management Pearls and Pitfalls Libby J. Smith, DO, FAOCO Saturday, May 12, 2012 96 th Annual Clinical Assembly Workshop Goals Who? Diagnose? Treat? Complications? Cases Larynx Voice