World Journal of Otorhinolaryngology-Head and Neck Surgery (2018) 4, 130e134

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.keaipublishing.com/WJOHNS; www.wjent.org

Research Paper

Voice outcome measures after flexible

endoscopic injection laryngoplasty
Abdul-Latif Hamdan a,*, Marwan Rizk b, Elie Khalifee a,
Georges Ziade a, Maher Kasti c

a
Department of Otolaryngology and Head & Neck Surgery, American University of Beirut-Medical
Center, Lebanon
b
Department of Anesthesiology, American University of Beirut-Medical Center, Lebanon
c
Department of Otolaryngology, Head & Neck Surgery, Rafic Hariri University Hospital, Lebanon

Received 13 April 2018; accepted 17 April 2018

Available online 4 July 2018

KEYWORDS Abstract Objective: To report voice outcome measures after injection laryngoplasty using
Injection; the transnasal or transoral flexible endoscopic technique.
Laryngoplasty; Methods: A retrospective review of all patients who underwent flexible endoscopic injection
Transnasal; laryngoplasty between June 2010 and August 2016 was carried out. Only those patients who
Transoral; had pre- and post-injection voice outcome measures recorded were included. Voice outcome
Flexible endoscopic; measures recorded included perceptual voice evaluation using GRBAS, Voice Handicap Index-
Vocal fold paralysis 10 (VHI-10), maximum phonation time (MPT) and closed quotient (CQ) before and after treat-
ment.
Results: Forty-six patients were identified, of which 32 had pre- and post-injection voice
outcome measures recorded. There were 19 males and 13 females. The mean age was 56.97
years (range 20e86 years) and the most common indication was unilateral vocal fold paralysis.
Thirteen patients had a transnasal flexible endoscopic injection), while 19 patients were in-
jected transorally. Following injection laryngoplasty, there was significant improvement in
the mean grade of dysphonia (2.81 vs. 1.22, P < 0.01, roughness (2.44 vs. 1.34, P < 0.01),
breathiness (2.72 vs. 1.13, P < 0.01), asthenia (2.78 vs. 1.06, P < 0.01), and strain (2.44 vs.
1.19, P < 0.01), MPT (3.85 s vs. 9.85 s, P < 0.01) and mean CQ (0.19 vs. 0.46, P < 0.01). There
was also a decrease in the mean VHI-10 score (33.31 vs. 7.94, P < 0.01).
Conclusion: s: Patients achieved significant improvement in both subjective and objective
voice measures after flexible endoscopic injection laryngoplasty via the nasal or transoral

* Corresponding author. Fax: þ961 1 350000.

E-mail address: ah77@aub.edu.lb (A.-L. Hamdan).
Peer review under responsibility of Chinese Medical Association.

Production and Hosting by Elsevier on behalf of KeAi

https://doi.org/10.1016/j.wjorl.2018.04.005
2095-8811/Copyright ª 2018 Chinese Medical Association. Production and hosting by Elsevier B.V. on behalf of KeAi Communications Co.,
Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Voice outcome measures 131

route. Voice outcomes were comparable to those reported for other approaches. This tech-
nique provides an alternative approach for the management of patients with vocal fold paral-
ysis or glottal insufficiency.
Copyright ª 2018 Chinese Medical Association. Production and hosting by Elsevier B.V. on
behalf of KeAi Communications Co., Ltd. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Methods

Injection laryngoplasty was initially described by Bruening Subjects

in 1908 for the treatment of unilateral vocal fold paralysis.1
Since its inception, the indications for this technique have After Institution Review Board approval was obtained, a
increased to include other etiologies of glottal insufficiency retrospective chart review of all patients who underwent
including vocal fold bowing, atrophy and paresis. With the injection laryngoplasty under local anesthesia through the
goal of restoring the normal phonatory position of the vocal working channel of a flexible endoscope either transnasally
fold, various injection techniques have been described or transorally between June 2010 and August 2016 was
based on the clinical presentation and etiology of the conducted. Only patients who had documentation of voice
glottal insufficiency. Both anatomic and technical consid- outcome measures before and after the procedure were
erations have been thoroughly discussed in the literature included in the study. Not all voice outcome measures were
with emphasis on needle position and the type and amount recorded for all patients. All patients had perceptual voice
of filler material used. In patients with unilateral vocal fold evaluation preoperatively and post-operatively.
paralysis and an intact vibratory surface, the needle is The patients’ age and gender, indication for injection,
usually inserted lateral to the vocal process, whereas in material injected, site of injection and amount injected
patients with vocal fold scarring or where there is tissue were recorded. Voice outcome measures collected included
loss, the injection is usually placed more anterior and the Voice Handicap Index-10 (VHI-10)11, perceptual evalu-
medial to restore the vibratory margin of the vocal fold.2 ation using the GRBAS grading system12, maximum phona-
With the widespread performance of injection lar- tion time, and the closed quotient. The closed quotient was
yngoplasty in the office setting, various techniques and ap- defined as the number of closed frames/the total number
proaches have been described, all of which have shown of frames (open þ closed) on videostroboscopy.13
promising results with significant improvement in both sub-
jective and objective voice outcome measures.3e6 The most
commonly used approaches are the per-oral and percutaneous Technique
routes through the thyroid cartilage, thyrohyoid membrane,
or cricothyroid membrane. The choice of approach is primarily With the patient awake in the sitting position, the pharynx
determined by the surgeon’s experience and preference, the was sprayed with 2% lidocaine. The nasal cavity was
patient’s orofacial and neck anatomy, patient tolerance, and decongested and anesthetized using pledgets soaked in 1%
the availability of instrumentation. lidocaine with epinephrine 1:100,000 mixed with oxy-
Although the transnasal endoscopic approach has been metazoline hydrochloride 0.1%. After several minutes, the
previously reported for steroid injection as an alternative flexible fiberoptic laryngoscope with a working channel
treatment for benign vocal fold lesions, only four articles in (Karl Storz Model 11001UD1; El Segundo, CA) was intro-
the literature have described the technique for vocal fold duced through either the nasal cavity or through the
medialization.7e10 Trask et al7 reported 20 patients who modified Guedel oral airway. The transoral approach was
underwent vocal fold augmentation using a transnasal used when nasal obstruction would not allow transnasal
endoscope which was initially designed for in-office trans- insertion, or when the patient was on anticoagulants. Four
nasal esophagoscopy. All patients except one tolerated the percent lidocaine gel was applied to the dorsum and base of
procedure and adequate medialization was achieved in all tongue prior to placement of the oral airway. Next, using a
cases. In 2015, Hamdan et al9 reported subjective voice 1.8 mm Teflon catheter (BTC Medical Europe Srl, Valeggio
outcome measures using the transnasal approach in a group sul Mincio, Italy)passed through the working channel,
of patients with glottal insufficiency. There was significant 2 ml of 2% lidocaine were applied above the palate, at the
subjective voice improvement and a reduction or complete epiglottis and at the vocal folds while the patient is asked
closure of the glottal gap in all patients, though no objective to phonate. Once the endolarynx was adequately anes-
voice measures were reported. More recently the transoral thetized, a 19-gauge flexible endoscopic needle (BTC
flexible endoscopic injection variation of the technique Medical Europe Srl, Valeggio sul Mincio, Italy) was passed
using the modified Guedel oral airway (Teleflex, Westmeath through the working channel of the endoscope and inserted
Ireland) has also been described. either lateral to the vocal process in cases of unilateral
The goal of this study is to report voice outcome mea- vocal fold paralysis, or in the mid-portion of the vocal fold
sures after injection laryngoplasty using either the trans- lateral to the vocal ligament in cases of vocal fold atrophy
nasal or transoral flexible endoscopic injection technique. or volume loss, and hyaluronic acid (Restylane, Galderma
132 A.-L. Hamdan et al.

SA Lausanne, Switzerland)injected via a 3 ml syringe. The (P < 0.01), roughness from 2.44 to 1.34 (P < 0.01),
patient was asked to phonate during the injection until the breathiness from 2.72 to 1.13 (P < 0.01), asthenia from 2.78
desired voice outcome was achieved. to 1.06 (P < 0.01), and strain from 2.44 to 1.19 (P < 0.01),
see Fig. 1. All patients had a decrease in the grade of
Statistics dysphonia. Twenty-eight patients (88%) had a decrease in
roughness, 29 patients (91%)in breathiness, 30 patients
Means and standard deviations were reported for contin- (94%) in asthenia, and 27 patients (84%) in strain. There was
uous variables, whereas frequencies and percentages were a significant increase in the MPT in all subjects with a sig-
reported for categorical variables. A paired Student t-test nificant difference in the mean MPT before and after in-
was used to compare means. Results were considered sig- jection (3.85 s vs. 9.85 s, P < 0.01) for the entire group.
nificant at P < 0.05. Data was analyzed using SPSS version There was also a significant increase in the closed quotient
23.0 (SPSS Inc, Chicago, Ill). in 23 out of 24 patients (96%), with a significant difference
in the mean before and after (0.19 vs. 0.46, P < 0.01) for
the entire group (Table 2).
Results
Complications
Demographic data
Three patients (9%) developed inflammatory reactions at
Forty-six patients who underwent awake injection lar- the injection site that were treated with systemic steroids
yngoplasty in the office using the flexible endoscope trans- and resolved.
nasally or transorally were identified. Of these, 32 had
documented voice outcome measures before and after the
procedure, and met the selection criteria for this study. The Discussion
mean age was 56.97 years (range 20e86 years). There were
19 males and 13 females. Thirteen patients (41%) were Numerous reports in the literature have described the
injected using the transnasal route and 19 patients (59%) transoral and percutaneous approaches for injection
using the transoral approach. Hyaluronic acid (Restylane laryngoplasty.14e17 Most of these have reported favorable
Galderma SA Lausanne, Switzerland) 0.20e0.80 ml voice outcomes with few complications. Amin18 has reported
(mean Z 0.51 ml) was injected. The indication, side of in- the tolerance rate and quality of life survey results in 10
jection, material and amount injected are summarized in patients who underwent injection laryngoplasty using the
Table 1. thyrohyoid approach. His findings support the usefulness of
this approach for vocal fold augmentation. Lee et al19 has
Voice outcome measures similarly reported favorable voice outcomes in patients un-
dergoing injection laryngoplasty percutaneously using Poly-
There was a decrease in the Voice Handicap Index-10 after acrylomide Hydrogel. In his report of 34 patients, there was
injection for all subjects with a significant difference in the significant improvement in the perceptual parameters,
mean before and after injection laryngoplasty for the acoustic measures, mucosal wave, and glottic closure post-
entire group (33.31 vs. 7.94, P < 0.01). Perceptually, the operatively. Chandran et al20 reported the Australian expe-
overall grade of dysphonia decreased from 2.81 to 1.22 rience of 34 injections performed under either local or
general anesthesia with improvement in the VHI-10, all
perceptual parameters except asthenia, and a less than 10%
complication rate. Barbu et al21 in their investigation on the
Table 1 Patient information.
feasibility of bed side injection laryngoplasty using the
Total subjects 32 transoral approach in the immediate post-operative period
Gender
Male 19
Female 13
Diagnosis
Vocal cord paralysis 27
S/p cordectomy 3
Vocal fold atrophy/bowing 2
Material injected
Restylanea 32 (39)
Side of injection
Right 8
Left 17
Bilateral 7
Age (years)b 56.97  19.39 (20.00e86.00)
Amount injected (ml)b 0.51  0.17 (0.20e0.80)
a
Number of injections.
Fig. 1 Perceptual evaluation before and after injection
b
Mean  SD (Range).
laryngoplasty.
Voice outcome measures 133

thyrohyoid approach, access to the most anterior and pos-

Table 2 Voice outcome measures before and after in-
terior portion of the vocal folds is often restricted, and
jection laryngoplasty.
insertion of the needle can be further challenged in pa-
Voice outcome Mean  St.dev Mean  St.dev P- tients with obscure neck landmarks.24
measures (Before) (After) value The flexible endoscopic approaches provide a viable
Maximum phonation 3.85  1.00 9.85  2.62 <0.01 alternative for injection laryngoplasty which obviates the
time (s) need for an assistant. The flexible endoscopic transoral
(n Z 20) approach in addition, is particularly useful in cases where
Closed quotient 0.19  0.15 0.46  0.09 <0.01 nasal anatomy limits scope insertion, or when concurrent
(n Z 24) anticoagulation increases the risk of iatrogenic epistaxis
Voice Handicap 33.31  3.82 7.94  2.84 <0.01 with the transnasal approach. Constraints of the flexible
Index-10 endoscopic technique include the offset working channel
(n Z 16) which makes right side injection challenging in some, the
additional cost of the endoscopic needle, and the un-
avoidable loss of injectable material in the long flexible
endoscopic needle which can be partially circumvented by
have reported advancement in oral intake in 70 percent of injecting saline to flush through the injectate.
patients, thus supporting the importance of early interven- Limitations of this study include the relatively small
tion. Mohammed et al22 reported their experience in the UK number of patients and the lack of all voice outcome
with 21 patients undergoing injection laryngoplasty using the measures for all patients. In addition, no data on patient
thyrohyoid approach, and have similarly demonstrated tolerance of the procedure was available, although no
improvement in the VHI-10 score 3 and 6 months after in- cases were aborted. Nonetheless, this study adds to the
jection. Similar results were reported by other groups also growing body of literature on available techniques for
highlighting improvement in the median Voice Performance awake injection laryngoplasty, their voice outcomes, and as
Questionnaire (VPQ) score and all perceptual vocal param- such augments the laryngologist’s armamentarium.
eters following the injection.23
In contrast, there have been few reports describing the
flexible endoscopic injection technique for vocal fold Conclusion
augmentation.7,9,10 The transnasal flexible endoscopic
approach for injection laryngoplasty was initially described The flexible endoscopic approach via the nasal or oral route
in 2005 by Trask et al7 in their report of 20 patients with is a viable option for injection laryngoplasty. Both allow for
glottal insufficiency. The procedure was performed in the completion of the procedure without the need of an assis-
outpatient clinic setting thus eliminating the additional tant. The transoral route is useful for patients with narrow
cost of using the operating room. It was of particular value nasal passages or who are anticoagulated. Voice outcome
for those patients with difficult laryngeal exposure or at measures are comparable to those reported for other ap-
high risk for general anesthesia.7 In 2015, Hamdan et al9 proaches. Familiarity with multiple injection approaches
reported voice outcome measures in 16 patients with empowers the laryngologist managing patients with vocal
glottal insufficiency who underwent transnasal injection fold paralysis or glottal insufficiency.
laryngoplasty. This included a significant decrease in the
mean score for perceptual parameters, and a marked
reduction or closure of the glottal gap in all subjects. More References
recently, the transoral flexible endoscopic injection tech-
nique as a variant to the transnasal approach using the 1. Lewy RB. Experience with vocal cord injection. Ann Otol Rhinol
same flexible endoscope with a working channel has been Laryngol. 1976;85:440e450.
described by the same group.10 2. Courey MS. Injection laryngoplasty. Otolaryngol Clin N Am.
In the current study, we report the voice outcome 2004;37:121e138.
measures for injection laryngoplasty using the flexible 3. Upton DC, Johnson M, Zelazny SK, Dailey SH. Prospective
endoscope passed through the nose or oral cavity. There evaluation of office-based injection laryngoplasty with hyal-
uronic acid gel. Ann Otol Rhinol Laryngol. 2013;122:541e546.
was significant improvement noted in the mean grade of
4. Reiter R, Rudolf R, Brosch S, Sibylle B. Laryngoplasty with hy-
dysphonia, roughness, breathiness, asthenia and strain. aluronic acid in patients with unilateral vocal fold paralysis. J
There was also a significant improvement in all other voice Voice. 2012;26:785e791.
outcome measures including VHI-10, MPT and closed quo- 5. Damrose EJ. Percutaneous injection laryngoplasty in the
tient. These results are similar with those published for the management of acute vocal fold paralysis. Laryngoscope. 2010;
percutaneous and transoral approaches. 120:1582e1590.
Despite the widespread use of the percutaneous and 6. Birkent H, Sardesai M, Hu A, Merati AL. Prospective study of
transoral approaches, a major limitation of these ap- voice outcomes and patient tolerance of in-office percuta-
proaches is the need for an assistant to handle the endo- neous injection laryngoplasty. Laryngoscope. 2013;123:
scope and allow concurrent visualization of the vocal folds 1759e1762.
7. Trask DK, Shellenberger DL, Hoffman HT. Transnasal, endo-
during the injection. In the transoral approach, the pa-
scopic vocal fold augmentation. Laryngoscope. 2005;115:
tient’s gag reflex may lead the procedure to be aborted.14 2262e2265.
The cricothyroid approach is limited by difficulty in visu- 8. Wang CT, Lai MS, Liao LJ, Lo WC, Cheng PW. Transnasal
alizing the tip of the needle during the procedure.15 In the endoscopic steroid injection: a practical and effective
134 A.-L. Hamdan et al.

alternative treatment for benign vocal fold disorders. Laryn- 17. Getz AE, Scharf J, Amin MR. Thyrohyoid approach to cidofovir
goscope. 2013;123:1464e1468. injection: a case study. J Voice. 2005;19:501e503.
9. Hamdan AL, Ziade G, Jaffal H, Skaff G. Transnasal injection 18. Amin MR. Thyrohyoid approach for vocal fold augmentation.
laryngoplasty. Ann Otol Rhinol Laryngol. 2015;124:474e479. Ann Otol Rhinol Laryngol. 2006;115:699e702.
10. Hamdan Al, Rizk M, Ayoub C, Ziade G. Injection laryngoplasty 19. Lee SW, Son YI, Kim CH, Lee JY, Kim SC, Koh YW. Voice out-
through a transoral approach using the Guedel oral airway. comes of polyacrylamide hydrogel injection laryngoplasty.
Acta Otorhinolaryngol Ital. 2017;37:444e446. Laryngoscope. 2007;117:1871e1875.
11. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development 20. Chandran D, Woods C, Ullah S, Ooi E, Athanasiadis T. A
and validation of the voice handicap index-10. Laryngoscope. comparative study of voice outcomes and complication rates in
2004;114:1549e1556. patients undergoing injection laryngoplasty performed under
12. Hirano M, ed. Psycho-acoustic Evaluation of Voice: GRBAS local versus general anaesthesia: an Adelaide voice specialist’s
Scale for Evaluating the Hoarse Voice. Clinical Examination of experience. J Laryngol Otol. 2017;131:S41eS46.
Voice. New York: Springer-Verlag; 1981:81e84. 21. Barbu AM, Gniady JP, Vivero RJ, Friedman AD, Burns JA.
13. Carroll TL, Wu YH, McRay M, Gherson S. Frame by frame Bedside injection medialization laryngoplasty in immediate
analysis of glottic insufficiency using laryngovideostroboscopy. postoperative patients. Otolaryngol Head Neck Surg. 2015;153:
J Voice. 2012;26:220e225. 1007e1012.
14. Andrade FPA, Carrau RL, Buckmire RA. Safety and cost- 22. Mohammed H, Masterson L, Gendy S, Nassif R. Outpatient-
effectiveness of intra-office flexible videolaryngoscopy with based injection laryngoplasty for the management of unilat-
transoral vocal fold injection in dysphagic patients. Am J eral vocal fold paralysis e clinical outcomes from a UK centre.
Otolaryngol. 2006;27:319e322. Clin Otolaryngol. 2016;41:341e346.
15. Jin SM, Park CY, Lee JK, Ban JH, Lee SH, Lee KC. Trans- 23. Powell J, Carding P, Birdi R, Wilson JA. Injection laryngoplasty
cutaneous injection laryngoplasty through the cricothyroid in the outpatient clinic under local anaesthetic: a case series
space in the sitting position: anatomical information and of sixty-eight patients. Clin Otolaryngol. 2014;39:224e227.
technique. Eur Arch Otorhinolaryngol. 2008;265:313e319. 24. Clary MS, Milam BM, Courey MS. Office-based vocal fold in-
16. Lee SW, Kim JW, Koh YW, Shim SS, Son YI. Comparative analysis jection with the laryngeal introducer technique. Laryngo-
of efficiency of injection laryngoplasty technique for with or scope. 2014;124:2114e2117.
without neck treatment patients: a transcartilaginous
approach versus the cricothyroid approach. Clin Exp Oto-
rhinolaryngol. 2010;3:37e41. Edited by Jie Gao