Учебники / Operative Techniques in Laryngology Rosen 2008

202	VF Augmentation – Microlaryngoscopy
31.6	Postoperative Care
31	and Complications

The voice rest requirement of postoperative care for patients with deep vocal fold injection is highly variable. After lipoinjection of the vocal fold, 3–6 days of voice rest, and a course of oral steroids are recommended. Other deep vocal fold injections require significantly fewer days of voice rest or no voice rest. For nonautologous material injections (CaHA, Teflon, Gelfoam), a single dose of antibiotics is used, given that a nonhuman material is placed in the body.

Complications of deep vocal fold injection include:

■Airway obstruction

■Infection at the injection site

■Overinjection

■Underinjection

■Allergic reaction

■Superficial injection

 

Airway obstruction is rare and can be treated with oral or intravenous steroids, antibiotics, airway observation, and humidification. If the airway obstruction is severe, then the treatment options include intubation to allow laryngeal edema to resolve or tracheotomy to bypass the airway obstruction.

Swallowing difficulties can also occur from the irritation and pain associated with vocal fold injection. Most pain and swallowing difficulties are minor and are treated with Tylenol or nonsteroidal over-the-counter medicine.

Complication of overor underinjection for deep vocal fold injection can occur. Approximately 3–6 months should be allowed for the injected vocal fold material to settle completely before deciding whether excessive vocal fold injection material has been deposited. Removal of overinjected material can be done via suspension microlaryngoscopy, and performing a lateral cordotomy and cold steel dissection down to the injected material and removing the material partially to correct

Fig. 31.9  Fat in Merocel-lined funnel

Fig. 31.8  Liposuction technique

Fig. 31.10  Fat from lipoinjection needle	Fig. 31.11  The appropriate amount of overcorrection (100%) used for
	autologous lipoinjection

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the over injection of material (see Chap. 12, “Management and Prevention of Complications Related to Phonomicrosurgery”). Accidental injection of augmentation material into the superficial aspect of the vocal fold is possible when a fine gauge needle is used and the depth of the injection is not controlled. One must take great care to control the depth of the injection needle. If superficial injection occurs, the material should be removed as soon as possible. The material can usually be easily removed via a microflap approach (see Chapter 10, “Principles of Phonomicrosurgery”).

Key Points

■Vocal fold augmentation (deep) is a versatile and essential procedure for a variety of voice disorders associated with glottal insufficiency.

■Vocal fold augmentation has an advantage of avoiding an open surgical procedure and involves a quick and prompt recovery.

■Vocal fold augmentation (deep) can be performed via microlaryngoscopy (via general anesthesia) or endoscopically under local anesthesia.

■Precise needle placement and careful attention to the vocal fold tissue during injection are critical to successful vocal fold injection.

Selected Bibliography

1Brandenburg JH, Unger JM, Koschkee D (1996) Vocal cord injection with autogenous fat: a long-term magnetic resonance imaging evaluation. Laryngoscope 106(Pt. 1):174–180

2Cantarella G, Mazzola RF, Domenichini E, Arnonr F, Maraschi B (2005) Vocal fold augmentation by autologous fat injection with lipostructure procedure. Otolaryngol Head Neck Surg 132:239–243

3Chen YY, Pai L, Lin YS, Wang HW, Hsiung MW (2003) Fat augmentation for nonparalytic glottic insufficiency. ORL J Orothinolaryngol Relat Spec 65:176–183

4Hsiung MW, Lin YS, Su FW, Wang HW (2003) Autogenous fat injection for vocal fold atrophy. Eur Arch Otorhinolaryngol 260:469–474

5Laccourreye O et al (2003) Intracordal injection of autologous fat in patients with unilateral laryngeal nerve paralysis, long-term results from the patient’s perspective. Laryngoscope 113:541–545

6Mikaelian DO, Lowry LD, Sataloff RT (1991) Lipoinjection for unilateral vocal cord paralysis. Laryngoscope101:465–468

7Shaw GY et al (1997) Autologous fat injection into the vocal folds: technical considerations and long-term follow-up. Laryngoscope 107:177–186

8Mikus JL, Koufman JA, Kilpatrick SE (1995) Fate of liposuctioned and purified autologous fat injections in the canine vocal fold. Laryngoscope 105:17–22

9Nakayama M, Ford CN, Bless DM (1993) Teflon vocal fold augmentation: failures and management in 28 cases. Otolaryngol Head Neck Surg 109(Pt. 1):493–498

10Remacle M, Lawson G, Delos M, Jamart J (1999) Correcting vocal fold immobility by autologous collagen injection for voice rehabilitation. A short-term study. Ann Otol Rhinol Laryngol 108:788–793

11Rihkanen H (1998) Vocal fold augmentation by injection of autologous fascia. Laryngoscope 108(Pt. 1):51–54

12Rosen CA (1998) Phonosurgical vocal fold injection: Indications and techniques. Oper Tech Otolaryngol Head Neck Surg 9:203–209

13Schramm VL, May M, Lavorato AS (1978) Gelfoam paste injection for vocal cord paralysis: temporary rehabilitation of glottic incompetence. Laryngoscope 88(Pt. 1):1268–1273

Chapter 32

Superficial Vocal Fold Injection	32

32.1Fundamental and Related Chapters

Please see Chaps. 8, 10, and 23 for further information.

32.2Disease Characteristics and Differential Diagnosis

Superficial vocal fold injection involves placement of a lamina propria replacement substance into the superficial aspect of the vocal fold to restore pliability. This procedure is done via high- poweredmicrolaryngoscopywithafine-gaugeneedle(27–30g). This procedure is aimed at correcting vibratory deficits of the vocal fold(s), not providing global augmentation.

The most commonly used materials presently available for superficial vocal fold injection are collagen based materials such as Cymetra, Zyplast, or Cosmoplast. These materials are all temporary in nature but can last up to 1 year. In addition, these materials may induce new, native extracellular matrix protein recruitment. It is likely that new lamina propria substitutes/replacement will be developed in the near future, which may be able to be delivered via a superficial vocal fold injection approach. Cross-linked hyaluronic acid-based substances have proven not to be of any value when placed superficially, and thus are contraindicated for this procedure.

The best prediction of success is a positive saline-infusion trial. A saline-infusion trial involves superficial injection of saline or diluted epinephrine underneath the epithelium to determine if a substance such as collagen could be subsequently injected into the vocal fold in the area of the focal lamina propria defect or vocal fold scar. If the saline-infusion trial is positive, then it is best to wait several minutes and/or “milk” the saline out of the vocal fold and then proceed with the superficial vocal fold injection. If the scar is too severe in nature, then the saline will track to locations other than those desired, and the patient will not respond well to a superficial vocal fold injection.

Superficial vocal fold injection is used in select cases of vocal fold scar. In addition, there are instances of a very focal defect of the lamina propria that would be suitable for augmentation via a superficial vocal fold injection approach.

32.3Surgical Indications and Contraindications

Indications include:

■Mild-to-moderate vocal fold scar

■Focal lamina propria defect

■A positive saline-infusion trial

Contraindications include:

■Need for global augmentation, such as seen in patients with vocal fold paresis, vocal fold paralysis, vocal fold atrophy

■Negative saline-infusion trial

■Sulcus vocalis (relative)

32.4Surgical Equipment

Equipment needed comprises:

■Phonomicrosurgery tray (see Table 10.1)

■A fine-gauge injection needle and device (27 or 30 g)

■Injection device can be designed from a fine-gauge butterfly needle, with the wings of the needle removed and cup forceps used to deliver the needle down to the vocal fold. Alternatively, an orotracheal injector with a disposable 27-g needle attached (Medtronic Xomed, Jacksonville, Fla.) serves the purpose for a superficial vocal fold injection extremely well.

32.5Surgical Procedure

Superficial vocal fold injection via microsuspension laryngoscopy allows for the precise and controlled placement of vocal fold injection material (collagen, etc.) into the most superficial aspect of the vocal fold. This procedure is done with high power microlaryngoscopy and a fine-gauge injection needle (27–30 g).

1.Review most recent preoperative videostroboscopy immediately before or during the operation to identify the specific pathology and location that requires vocal fold injection.

	206	Superficial Vocal Fold Injection
	2.	Placement of a large-bore laryngoscope (see Chap. 10)
	3.	Vocal fold palpation with a slightly curved blunt instru-
		ment is helpful to identify completely the area of the vocal
		fold pathology and the nature of the pathology (vocal fold
32		scar).
	4.	If there is a concern or question about the exact nature and

severity of the vocal fold scar, then often a preliminary injection with 1:10,000 epinephrine or saline placed superficially in the area of the pathology will clearly delineate the

Fig. 32.1  Saline-infusion trial

 

area of the deficit as well as the severity of the scar (Fig. 32.1).

5.Under high-power magnification, the vocal fold injection is done using a 27or 30-g needle. The entry site should be 3–5 mm away from the intended vocal fold injection deposition to prevent extrusion of the injection material. It is best to have the entry site away from the proposed area of infiltration and then tunnel the needle submucosally to the intended area of injection (Fig. 32.2).

6.The vocal fold injection needle should be as superficial as possible after its entry through the epithelium, and is often visible through the mucosa as the needle is tunneled forward to the vocal fold pathology site.

7.There is no preset volume of material to be injected. The defect to be addressed will determine the volume to be injected. Typically, these injections only require 0.2–0.4 ml of material (Fig. 32.3).

32.6Postoperative Care and Complications

Postoperatively:

■No need for antibiotics

■No indication for steroids

■Voice rest for approximately 6 days

■Voice therapy can start shortly after the resumption of voice use.

Fig. 32.2  Superficial vocal fold injection with needle tunneled to area	Fig. 32.3  Appearance after superficial vocal fold injection
of intended deposit

 

With regard to complications, if there is an overinjection of superficial vocal fold injection that is not resolved with a short period (approximately 1–2 months) and inhibits vocal fold function and voice quality, then the superficial material can be removed by making a small incision over the most lateral aspect of the injection location and removing part or all of the material.

Key Points

■Superficial vocal fold injection can be done to correct mild vocal fold scar or a focal lamina propria defect.

■Saline-infusion trial predicts the suitability for superficial vocal fold injection.

■Collagen-based materials are presently best suited for superficial vocal fold injection.

■In the future, new lamina propria replacement materials may be delivered via a superficial vocal fold injection approach.

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Selected Bibliography

1Ford CN, Bless DM, Loftus JM (1992) Role of injectable collagen in the treatment of glottic insufficiency: a study of 119 patients. Ann Otol Rhinol Laryngol 101:237–247

2Ford CN, Staskowski PA, Bless DM (1995) Autologous collagen vocal fold injection: a preliminary clinical study. Laryngoscope 105(Pt. 1):944–948

3Kass ES, Hillman RE, Zeitels SM (1996) The submucosal infusion technique in phonomicrosurgery. Ann Otol Rhinol Laryngol 105:341–347

4Zeitels SM, Vaughan CW (1991) A submucosal vocal fold infusion needle. Otolaryngol Head Neck Surg 105:478–479

Chapter 33
Peroral Vocal Fold Augmentation	33
in the Clinic Setting

33.1Fundamental and Related Chapters

Please see Chaps. 5, 14, 31, and 34 for further information.

33.2Disease Characteristics and Differential Diagnosis

Transoral vocal fold augmentation in the clinic setting is used to provide global vocal fold augmentation into the deep aspect of the vocal fold for patients with glottal insufficiency. Chapters 5 and 14 (“Glottic Insufficiency: Vocal Fold Paralysis, Paresis, and Atrophy” and “Principles of Vocal Fold Augmentation,” respectively) discuss the pertinent issues regarding glottal insufficiency and their subsequent treatment with vocal fold augmentation. Information regarding the specific indications and nature of the current materials available for augmentation are discussed in detail in Chaps. 5 and 14. The most common symptoms associated with patients with glottal insufficiency include the following:

■Dysphonia

■Decreased volume

■Vocal fatigue

■Odynophonia

■Dysphagia/Aspiration of liquids

■Compensated falsetto

Several advantages to performing peroral vocal fold augmentation in a clinic setting exist. The patient does not have to arrange transportation to and from the hospital nor undergo a general anesthetic, and does not have to be NPO before the surgical procedure. Furthermore, since the procedure is performed with the patient completely awake and in the upright position, vocal fold augmentation can be tailored to optimize the patient’s voice result by intermittently testing the voice throughout and at the completion of the procedure.

All patients should be counseled prior to injection regarding the expected duration of augmentation from injection. Duration varies with technique as well as with the type of material injected.

33.3Surgical Indications and Contraindications

Peroral vocal fold augmentation in the clinic setting is indicated in treatment of symptomatic glottal insufficiency due to any of the following factors:

■Unilateral vocal fold paralysis

■Vocal fold atrophy

■Vocal fold paresis

■Vocal fold scar

■Sulcus vocalis

■Soft tissue loss of the vocal fold(s)

Injection in the clinic setting can be used as a temporizing treatment to correct the patient’s glottal insufficiency or for permanent correction. A typical example is a patient with idiopathic unilateral vocal fold paralysis who presents early (1–3 months after onset) in the course of the disease. If the patient is aspirating, or significantly dysphonic and has significant vocal demands, then temporary augmentation via peroral vocal fold augmentation in the clinic is an excellent option. This addresses the patient’s vocal/swallowing needs, while allowing for spontaneous recovery of function and avoids a surgical procedure in the hospital or general anesthesia.

Vocal fold augmentation can also be offered to a patient as a minimally invasive opportunity to “test drive” their voice after correction of glottic insufficiency. This may help the patient decide if a permanent treatment option for their glottic insufficiency is desirable. This approach is referred to as a trial vocal fold augmentation.

Contraindications involve:

■Unstable cardiopulmonary status

■Inability to tolerate procedure under local anesthesia (i. e., hyperactive gag response or high level of anxiety)

■Use of anticoagulants (aspirin, nonsteroidal anti-in- flammatories, Coumadin)

■Ideally, the patient should be taken off any anticoagulant medication prior to any planned injection; however, clinical experience has shown that the procedure can be performed if medically unable to stop anticoagulant therapy.

■Inability to visualize the larynx adequately during the time of injection

■This may occur if the patient has significant hooding of the arytenoid or severe supraglottic constriction.

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Peroral VF Augmentation – Clinic

33.3.1Suitability for Peroral Vocal Fold Augmentation in the Clinic Setting

In order to be a suitable candidate for peroral vocal fold augmentation:

33 ■ The patient must tolerate a flexible laryngoscopy endoscopic exam, without excessive gag. Monitoring with a flexible endoscope is key to maintaining visualization, and a hyper-responsive gag may render any procedures impossible. However, it should be noted that gagging with a mirror or rigid peroral endoscope is not a contraindication.

■The patient must have an adequate oral opening (at least 2-cm intermaxillary distance).

■The patient must be able to remain reasonably still and upright in the exam chair for the duration of the procedure (typically 5–15 min). Patients with severe torticollis or head tremor are sometimes difficult to treat.

33.4Surgical Equipment

Surgical equipment needed (Fig. 33.1):

■Flexible laryngoscope (fiberoptic or distal chip)

■C-mount camera (attaches to flexible scope)

■Videomonitor for visualization

■3–6 ml of 4% lidocaine

■Curved Abraham cannula for delivery to topical lidocaine

■Cetacaine spray (benzocaine/tetracaine topical)

■Oxymetazoline and/or 2% Pontocaine (for nasal decongestant and anesthesia)

■Cotton nasal pledgets

■Disposable nebulization device

33.5Surgical Procedure

Peroral vocal fold augmentation comprises the following:

1.Topical anesthesia nasal/oropharynx

a)Topical oxymetazoline/Pontocaine 2% spray to nasal cavities (medication-soaked cotton nasal pledgets placed intranasally are also very helpful).

b)Topical Cetacaine spray to oral cavity (palate/posterior pharynx)

2.Videomonitoring/topical anesthesia of larynx

a)A video camera is attached to a flexible laryngoscope (distal chip flexible laryngoscope system preferred) is inserted through the nasal cavity (typically the side opposite the intended vocal fold to be injected) by an assistant, employing a “videocart system.” The scope is generally maintained slightly below the palate so that the tongue base and larynx can be easily viewed on the video monitor.

b)Four percent lidocaine drip onto larynx under flexible laryngoscope guidance (3–6 ml)

The patient is bent forward at the waist with the neck extended in a “sniffing” position to maximize laryngeal exposure. The tongue is grasped with gauze with the surgeon’s left hand. A 3-ml syringe of 4% lidocaine attached to an Abraham cannula is passed from the oral cavity into the pharynx under flexible laryngoscopy guidance. Approximately 1 ml is deposited over the tongue base, and 2–4 ml are dripped onto the vocal folds during phonation, producing the characteristic “laryngeal gargle” (Fig. 33.2). The maximum recommended dose of 4% lidocaine is approximately 7–8 ml (4.5 mg/kg; approximately 300 mg in 70-kg patient).

The initial dose is usually followed by a brisk cough, as the anesthetic is aspirated and then distributed over the laryngotracheal mucosa. Absence of the laryngeal gargle and cough may indicate that the patient has swallowed the anesthetic, and additional topical applications may be indicated until the desired effect is obtained.

Fig. 33.1  Equipment used for transoral vocal fold augmentation in the	Fig. 33.2  “Laryngeal gargle” of 4% lidocaine delivered via an Abraham
clinic (cotton pledgets, 4% plain lidocaine, Neosynephrine, Bioform in-
jection needle filled with Radiesse, Abraham cannula, drip catheter)	cannula

 

Fig. 33.3  Nebulization of 4% plain lidocaine for laryngeal anesthesia

Fig. 33.4  Drip catheter for applying 4% plain lidocaine to larynx via flexible laryngoscope with a working channel

An alternative method to obtain anesthesia of the larynx involves nebulization of lidocaine, using a simple disposable nebulization device (frequently used in the hospital for respiratory therapy) and an external source of pressurized air (often from an oxygen tank). Four percent plain lidocaine can be nebulized and inhaled peroral by the patient (Fig. 33.3). This method of anesthesia provides a simple and less physician-involved method for obtaining laryngeal anesthesia. Typically, 4–5 ml of plain lidocaine is nebulized over a 5- to 10-min period to achieve anesthesia of the larynx and pharynx. After the nebulization process, a curved Abraham cannula can be used to supplement any further need for laryngeal anesthesia on an as-needed basis and to test for complete anesthesia of the larynx and, specifically, the vocal folds.

Another technique to deliver anesthetic agent to the larynx is using a small Silastic, flexible cannula through the working channel of the flexible laryngoscope or an Endosheath™ with a working channel (Medtronic Xomed, Jacksonville, Fla.). This Silastic catheter (Olympus America, PW-2L-1.B, Center Valley, Pa.) is passed through the working channel

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of the flexible laryngoscope and used to deliver 4% plain lidocaine to the endolarynx during sustained phonation to achieve the “laryngeal gargle” as described above (Fig. 33.4). This catheter allows direct application of the anesthesia to the specific areas intended for the vocal fold injection and is very well tolerated by patients.

3.Transoral passage of the needle into the endolaryngeal region

a)The two most commonly used needles for peroral vocal fold augmentation in a clinic setting are the orotracheal injector device (Medtronic Xomed) and the injection needle developed by Bioform Medical (Bioform Medical, San Mateo, Calif.). Each of these injection devices use fine-gauge needles (27and 25-g, respectively.) The former device is curved for transoral injection, and the latter is malleable and can be bent to the appropriate dimensions and curvature needed for transoral vocal fold augmentation. In preparation for vocal fold injection, the intended injection material should be attached to the injection needle and “primed” to eliminate the dead space within the needle.

b)The patient holds his/her own tongue with gauze, or the surgeon grasps the tongue with the left hand. The needle is passed through the oral cavity and then advanced into the oropharynx under direct visualization from the flexible laryngoscope. The patient is instructed to phonate /a/ as the needle enters the oral cavity, which results in palatal raising, clearing the path into the oropharynx. The assistant should position the fiberoptic scope just above the palate, until the needle is visualized in the oropharynx.

c)The needle is then guided into the oropharynx and the endolarynx under endoscopic visualization, as the assistant follows closely behind with the flexible laryngoscope (Fig. 33.5). The assistant must be adept at manipulating the flexible scope; consistent visualization of the needle can be challenging in a narrow airway with copious secretions. The flexible scope should be positioned a few millimeters above the true vocal folds, providing a clear, well-illuminated view before, during, and immediately after the injection (Fig. 33.6).

4.Vocal fold injection

a)For unilateral vocal fold paralysis, the injection should be placed at two sites (Fig. 33.7): (1) the posterior aspect (lateral to the vocal process) and (2) the midmembranous vocal fold.

b)The initial injection should be at the posterior aspect of the vocal fold, where, typically, the most correction is needed.

c)The depth of injection should be into the substance of the vocal fold in a lateral position (see Chap. 14, “Principles of Vocal Fold Augmentation”). Care should be taken to avoid superficial placement into Reinke’s space, which will result in a stiff vocal fold and poor voice quality (Fig. 33.8).

d)If the subglottis begins to bulge during injection, then the needle should be withdrawn slightly. Once the posterior vocal fold is adequately medialized, a smaller additional amount can be deposited at the mid vocal fold, if needed.

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Peroral VF Augmentation – Clinic

33

Fig. 33.5  Transoral vocal fold augmentation in the clinic. Surgeon on the left with the assistant on the right and patient holding her own tongue

Fig. 33.6  Flexible laryngoscope image during peroral injection augmentation. The scope should be positioned a few millimeters above the true vocal folds, providing a clear, well-illuminated view

Fig. 33.7  Injection location(s) for deep vocal fold augmentation

e)If the injected substance extrudes from the puncture hole, then the material can be cleared by instructing the patient to cough or clear their throat (this is rarely a problem when a fine-gauge needle is used).

f)The injection should be carried out in a stepwise fashion, checking for improvement in the patient’s voice periodically.

For most injectables, the medialized vocal fold should be overinjected (past midline) to a variable degree, depending on the specific nature of the material and the primary goal

Fig. 33.8  Injection depth for deep vocal fold

of the procedure (long duration of the temporary agent versus immediate need for optimal voice function.) In general, the vocal fold is medialized until the voice is maximally improved, and then an additional 0.1–0.2 ml is injected to achieve overcorrection. This overcorrection is necessary, because all injectables have a small aqueous component that will be absorbed 3–5 days after injection. The total amount necessary for unilateral augmentation is typically less than 1 ml, but amount injected should be determined by the sound of the voice and appearance of the vocal fold, not by the volume injected.

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For patients with a bowed vocal fold due to atrophy/paresis or presbylaryngis, the injection differs slightly from the previous technique. These cases typically require injection principally in the midportion of the vocal fold, where the maximal glottal gap usually occurs. In severe cases of muscular atrophy, the posterior vocal fold can be augmented to fill in the atrophy that occurs just anterior to the vocal process. Again, overcorrection is the rule, even in the case of bilateral injections. Airway compromise should not be a concern, because the posterior (respiratory) glottis remains patent and in cases of vocal fold atrophy both vocal folds are usually fully mobile.

33.6Postoperative Care and Complications

Postoperative care includes:

■Immediately after vocal fold injection in the clinic, patients should be observed for a short period to monitor for any complications of the vocal fold injection, most notably, airway difficulties.

■Patients need to be instructed that they should not take anything orally for approximately 2 hours after vocal fold injection to allow adequate time for the local anesthesia to wear off. In addition, patients should take care as they resume oral intake to ensure that all aspects of the anesthesia are gone.

■The use of strict voice rest after vocal fold injection is not standardized and is often determined by the size of the vocal fold injection needle used and the individual surgeon’s preferences. Given that most vocal fold injections are now performed with a fine-gauge needle, prolonged voice rest (exceeding 24 hours) is most likely not indicated. Some surgeons use no voice rest; others

will use a 24-hour period of voice rest. The rationale for voice rest after vocal fold injection is to minimize loss of the injected material being extruded through the injection site(s) if immediate phonation is allowed.

■Antibiotics and steroids associated with the vocal fold injection are not typically indicated for this procedure.

■Patients should be instructed that, because of the vocal fold edema associated with the procedure, as well as possibly the overinjection of the augmentation material, optimal voice quality is typically not achieved for 1–2 weeks after vocal fold injection.

Complications of peroral vocal fold injection include inappropriate placement of the vocal fold injection material comprise:

■Either too superficially into Reinke’s space

■Very lateral into the paraglottic space

■Inferior into the subglottis

If these inappropriate locations of vocal fold injection are recognized during the procedure, then often the material can be “milked” out of the vocal fold with the use of an Abraham cannula, applying gentle lateral pressure to the vocal fold. If this is not possible, then it would be advisable that the vocal fold material, if permanent in nature (such as calcium hydroxylapatite) be removed under microlaryngoscopy with general anesthesia in the near future.

Key Points

■Peroral vocal fold augmentation in a clinic setting provides the patient an opportunity for permanent or temporary vocal fold augmentation under local anesthesia, obviating a trip to the operating room and general anesthesia.

■Appropriate patient selection is the key to successful peroral vocal fold augmentation. Patients should be cooperative and should not have a hyperactive gag reflex.

■Adequate anesthesia can be easily obtained for peroral vocal fold augmentation, with topical lidocaine and does not necessitate nerve blocks or sedation (orally or intravenously).

■Peroral vocal fold augmentation offers the unique advantage of having the patient unsedated and positioned in an upright position to monitor voice quality and vocal fold closure pattern during the injection. This allows for customization and maximum control of the vocal fold augmentation to optimize postoperative voice quality and function.

Selected Bibliography

1Arad-Cohen A, Blitzer A (1999) Office-based direct fiberoptic laryngoscopic surgery. Oper Tech Otolaryngol Head Neck Surg 9:238–242

2Bové MJ, Jabbour N, Krishna P, Rosen CA et al (2007) Operating room versus office-based injection laryngoplasty: a comparative analysis of reimbursement. Laryngoscope 117:226–230

3Chu PY, Chang SY (1997) Transoral Teflon injection under flexible laryngovideostroboscopy for unilateral vocal fold paralysis. Ann Otol Rhino Laryngol 106:783–786

4Simpson CB, Amin MR (2004) Office-based procedures for the voice. Ear Nose Throat J 83(Suppl.):6–9

5Simpson CB, Amin MR, Postma GN (2004) Topical anesthesia of the airway and esophagus. Ear Nose Throat J 83(Suppl.):2–5