Info

a yearb

vocal foldb

aAlso marketed as Hylaform plus, with a higher particle size (700-^m gel bead) which is the equivalent to Perlane. [Perlane is another NASHA gel (see Restylane) with particle size 1000 |im. We have limited experience with Perlane, but this should probablybe injected in the TA], Our experience in vocal folds injections ofthis is limited bSee Reference List

CNASHA monograph (see Reference List)

aAlso marketed as Hylaform plus, with a higher particle size (700-^m gel bead) which is the equivalent to Perlane. [Perlane is another NASHA gel (see Restylane) with particle size 1000 |im. We have limited experience with Perlane, but this should probablybe injected in the TA], Our experience in vocal folds injections ofthis is limited bSee Reference List

CNASHA monograph (see Reference List)

Disadvantages

Resorption has been noted after vocal fold injections with HA derivatives [11,13]: The extent of resorption in the human vocal fold is unknown for several of the existing preparations. It is possible that DiHA and HA derivatives with higher particle size (e.g. Perlane) show less resorption (H. Svanholm, personal communication). According to the documentation of DiHA (Deflux), this substance remains at least 3-5 years after treatment of vesicourethral reflux in the urinary tract [19, 21].

Complications

Complications of hyaluronan use are as follows:

— A slight inflammation or bleeding at the injection site has been noted in less than 4% of the injections [12]. Usually this inflammation resolves without treatment within a week. We have seen a few patients who had laryngitis after injection. This resolved with broad-spectrum antibiotics within a week. No long-term inflammation or granuloma formation has been noted after HA injections.

— A temporary decrease in mucosal wave pliability is sometimes noted after injections of Hylan B Gel or Restylane in the superficial LP (including Reinke's space). This is normalized within a few weeks. We are, however, aware of 1 patient with long-lasting vocal fold stiffness, reduced mucosal wave and a rough voice quality after superficial injection of DiHA. This substance is known to induce new soft tissue formation (mainly collagen) in the injected area [6], and it is possible that DiHA may induce some stiffness when injected into the superficial LP. On the other hand, animal experiments have shown positive viscoelastic properties in injected rabbit vocal folds after 6 months using this compound [4]; however, we caution against injection of DiHA or other HA derivatives with larger particle size (e.g. Perlane, Q-med Inc.) superficially in the LP until the effect of them has been studied more in detail. If these HA derivatives are used, the injections should be made into the thyroarytenoid muscle.

Technique

There are four techniques for injection [11,15], as illustrated in Fig. 8.5.3.

1. Under local anaesthesia through a transoral route using a curved cannula under with a rigid endoscope guidance. Cannula diameter is usually 27 G. Most often we use the Medtronic Xomed Oro-Tracheal laryngeal Injector.

2. Under local anaesthesia with a transcutaneous needle passed through the cricothyroid membrane under transnasal fiberscope guidance. This us usually performed with an intramuscular injection needle.

3. Under local anaesthesia transnasally via the working channel of a fiberscope (cannula size 23 G). At present, we use a specially designed catheter from Sugimed Inc.

4. Under general anaesthesia via a laryngoscope using a straight-injection cannula (diameter between 23 and 27 G). Several injection cannulas are available (e.g. the Medtronic Xomed Oro-Tracheal laryngeal Injector).

Methods 1-3 are usually performed as an in-of-fice procedure. In our previous studies, 67% of the injections were performed as an out-patient procedure [11], and currently this figure is even higher. Methods 2 and 3 require an assistant performing the fibrescopic examination while the surgeon injects. As topical anaesthetic we use lidocaine 2 or 4% given as spray or inhalation in the oral cavity, pharynx and larynx. Sometimes 10% lidocaine spray is added. In the transcutaneous method (no. 2) the local anaesthetic can be injected through the cricothyroid membrane prior to insertion of the intramuscular injection needle. It is important that the laryngeal reflexes be completely abolished during the injection and that it be performed with optimal vision of the glottic area. The amount of substance injected is determined on-line and glottal closure can be tested by asking the

Transoral Injection route

Fig. 8.5.3. Injection techniques: a transoral route; b transcutaneous route

Transoral Injection route

Fig. 8.5.3. Injection techniques: a transoral route; b transcutaneous route patient to phonate during the procedure. It is also possible to perform a stroboscopy directly after the injection. Normally we do not overin-ject, except for Hylan B gel, which is injected to achieve a slightly convex vocal fold edge. Usually the total amount of HA injected ranges between 0.15 up to maximum 1 ml depending on the cause and severity of GI. Patients with a large glottal gap due to unilateral paresis often receive larger amount of HA. The duration of the procedure is usually only a few minutes. In the local procedures, the patients are observed for about 1 h after the procedure and then discharged. One or 2 days voice rest is recommended after treatment.

Injections under general anaesthesia include all phonomicrosurgical procedures with dissection of sulcus vocalis and vocal fold scarring.

Restylane \ Perlane

Fig. 8.5.4. Recommended placement of different HA derivatives during injection treatment. Coronal plane of a vocal fold. FE free edge of vocal fold, VL vocal ligament, TA thyroarytenoid muscle

Restylane \ Perlane

Fig. 8.5.4. Recommended placement of different HA derivatives during injection treatment. Coronal plane of a vocal fold. FE free edge of vocal fold, VL vocal ligament, TA thyroarytenoid muscle

This is necessary to ensure optimal placement of the HA in the treated vocal fold (Fig. 8.5.4). Patients who do not tolerate a local procedure are also included in this group. The operations are usually same-day procedures. For the sulcus operations, a week of absolute voice rest is recommended.

References

1. Becker JM, Dayton MT, Fazio VW et al. (1996) Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study. J Am Coll Surg 183:297-306

2. Butler JE, Hammond TH, Gray SD (2001) Gender related differences ofhyaluronic acid distribution in the human vocal fold. Laryngoscope 111:907911

3. Chan RW, Gray SD, Titze IR (2001) The importance of hyaluronic acid in vocal fold biomech-nics. Otolaryngol HeadNeck Surg 124:607-614

4. Dahlqvist Â, Garskog 0, Laurent C, Hertegârd S, Ambrosio L, Borzacchiello A (2004) Viscoelastic-ity of rabbit vocal folds after injection augmentation. Laryngoscope 114:138-142

5. Filho J, Tsuji D, Nascimento P, Sennes L (2003) Histological changes in human vocal folds corre lated with aging: a histomorphometric study. Ann Otol Rhinol Laryngol 112:894-898

6. Hallen L, Dahlqvist Â, Laurent C (1998) Dextrano-meres in hyaluronan DiHA): a promising substance in treating vocal cord insufficiency. Laryngoscope 108:393-397

7. Hallen L, Johansson C, Laurent C (1999) Cross-linked hyaluronan (Hylan B gel): a new injectable remedy for treatment of vocal fold insufficiency - an animal study. Acta Otolaryngol (Stockh) 119:107-111

8. Hallén L, Testad P, Sederholm E, Dahlqvist A, Laurent C (2001) DiHA (dextranomeres in hyaluronan) injections for treatment of insufficient closure of the vocal folds. Early clinical experiences. Laryngoscope 111:1063-1067

9. Hammond TH, Gray SD, Butler JE (2000) Age- and gender related collagen distribution in human vocal folds. Ann Otol Rhinol Laryngol 109:913-920

10. Hertegârd S (2003) Hyaluronan vid fonokirurgisk behandling av sulcus vokalis samt ärrbildning i stämbanden. Poster presentation at the Annual Swedish Medical Association Conference, Stockholm, November 2003 [in Swedish]

11. Hertegârd S, Dahlqvist Â, Laurent C, Olofsson K, Sederholm E, Hallén L, Testad P (2002) Cross-linked hyaluronan (hylan B gel) and bovine collagen used as augmentation substances for treatment of patients with glottal insufficiency - evaluation of safety and vocal fold function. Laryngoscope 112:2211-2219

12. Hertegârd S, Dahlqvist Â, Laurent C, Borzacchiello A, Ambrosio L (2003) Viscoelastic properties of rabbit vocal folds after augmentation. Otolaryngol Head Neck Surg 128:401-406

13. Hertegârd S, Dahlqvist Â, Goodyer E, Maurer F (2004) Viscoelasticity in scarred rabbit vocal folds after hyaluronan injection: short term results. Abstract. Report presented at the Annual American Academy of Otolaryngology Head and Neck Surgery Conference, New York, September 2004

14. Hertegârd S, Dahlqvist Â, Laurent C, Olofsson K, Sederholm E, Hallén L, Testad P (2004) Cross-linked hyaluronan for injection treatment of glottal insufficiency: 2-year follow-up. Acta Otolaryngol (Stockholm) 124:1208-1214

15. Hirano M, Tanaka S, Tanaka Y, Hibi S (1990) Transcutaneous intrafold injection for unilateralvocal fold paralysis: functional results. Ann Otol Rhinol Laryngol 99:598-604

16. Lapcik L, De Smedt S, Demester J, Chabrecek P (1998) Hyaluronan: preparation, structure, properties, and applications. Chem Rev98:2663-2684

17. Larsen NE, Leshchiner E, Pollak CT, Balazs EA, Piacquadio D (1995) Evaluation of Hylan b (hylan gel) as soft tissue dermal implants. In: Mikos AG, Leong KW, Radomsky ML, Tamada JA, Yaszem-

ski MJ (eds) Polymers in medicine and pharmacy. Proc Materials Research Society. Spring meeting, April 1995. Materials Research Society, Pittsburgh, pp 193-197

18. Laurent T (1987) Biochemistry of hyaluronan. Acta Otolaryngol (Stockh) Suppl 442:7-24

19. Lackgren G, Wahlin N, Skoldenberg E, Stenberg A (2001) Long-term follow-up of children treated with dextranomer/hyaluronic acid copolymer for vesicoureteral reflux. J Urol 166:1887-1892

20. Manna F, Dentini M, Desideri P, Pita 0 de, Mortil-la E, Maras B (1999) Comparative chemical evaluation of two commercially available derivatives of hyaluronic acid (hylaform from rooster combs and restylane from streptococcus) used for soft tissue augmentation. J Eur Acad Dermatol Vener-eol 13:183-192

21. Agerup B, Wik Y (2001) NASHA. The monograph. Q-med AB. Uppsala, Sweden

22. Reed RK, Lilja K, Laurent T (1988) Hyaluronan in the rat with special reference to the skin. Acta Physiol Scand 13:405-411

23. Reed RK, Laurent UBG, Fraser JRE, Laurent T (1990) Removal rate of [3H] hyaluronan injected subcutaneously in rabbits. Am J Physiol 259^532-H535

24. Ward PD, Thibeault SL, Gray SD (2002) Hyaluronic acid: its role in voice. J Voice 16:303-309

Was this article helpful?

0 0
Stop Anxiety Attacks

Stop Anxiety Attacks

Here's How You Could End Anxiety and Panic Attacks For Good Prevent Anxiety in Your Golden Years Without Harmful Prescription Drugs. If You Give Me 15 minutes, I Will Show You a Breakthrough That Will Change The Way You Think About Anxiety and Panic Attacks Forever! If you are still suffering because your doctor can't help you, here's some great news...!

Get My Free Ebook


Post a comment