Management of Airway, Hoarseness, and Vocal Cord Dysfunction After Esophagectomy

Material

Length of effect

Comments

Gelfoam^TMa

4–6 weeks

Long track record, short duration

Zyplast^TMa (Bovine collagen)

4–6 months

Allergy testing required

Cymetra^TM (Micronized alloderm^TM)

2–4 months

No allergy, longer prep time, expensive, unpredictable reabsorbtion

Fat

2 + years

Autologous, forgiving, donor site morbidity, unpredictable length

Fascia

3 months

Effects last up to 1 year

Teflon^TMa

Permanent

Long lasting, granuloma formation, migration, VF stiffness

Radiesse^TM voice (Ca hydroxylapatite)

2 + years possibly permanent

Long lasting

Radiesse^TM voice gel

1–2 months

Temporary

^a Rarely used anymore

Multiple techniques have been described for vocal cord injections. The intended injection location is in the paraglottic space or to the medial or lateral aspect of the thyroarytenoid muscle, depending on the material used. Placement of the injection lateral to the vocal process will allow the process to rotate medially [8, 9]. Care to avoid a superficial injection into Reinke’s space is paramount as a superficial injection can impair or cause loss of the vibratory function of the vocal fold, with worsening of voice. In the correctly selected patient, an in the office awake injection (transcutaneous or per-oral approach) has equal results as to those that are placed in the operating room under general anesthesia via direct laryngoscopy with telescopic or microscopic guidance [8]. Cummings and colleagues reported an 85 and 88 % subjective improvement of dysphagia and aspiration after hydroxylapatite medialization thyroplasty [7].

Framework Surgery for Unilateral Vocal Cord Dysfunction

Framework surgery for unilateral vocal fold dysfunction is a standard treatment for long-term VCP in the nonradiated neck, with medialization laryngoplasty (type 1 thyroplasty) and arytenoid adduction being the most widely performed procedures. Any framework surgery must be carefully considered in the radiated neck as chondroradionecrosis is a devastating though rare complication. Many times, long-lasting injections, even when needing to be repeated, are a safer option than framework surgery in this special population.

Medialization laryngoplasty is a long-term solution that medializes the paralyzed vocal cord to allow contact during vocalization with the contralateral cord. The procedure can be and usually is done under local anesthesia. A window is created in the thyroid cartilage preserving the inner perichondrium, and an implant (preformed or carved by the surgeon) is placed in the middle third of the vocal cord. Placement can be tailored specifically for each patient based on where the cord has lateralized and where the greatest glottis gap is located. Voice quality can be measured intraoperatively since the procedure is done under local anesthesia and adjustments in placement and size of the implant can be done while the patient is in the operating room. Due to the trauma and placement of a foreign body, a good voice on the operating room table can and will become rough and breathy due to edema in the subsequent days. It is recommended the patient be observed overnight in the hospital in case of significant airway edema and three doses of IV steroids be given. While medialization laryngoplasty is expected to be a permanent solution to medialize the vocal cord, the procedure can be reversed and the implant removed or adjusted as needed.

Arytenoid adduction can be an added procedure for selected cases, mainly those with a large posterior gap and vocal processes that do not contact during phonation. Arytenoid adduction is done by suturing the muscular process of the immobile arytenoid to the anterior cricoid cartilage. This lowers the position of the vocal process, medializes and stabilizes the vocal process, and rotates the arytenoid cartilage [1]. In the properly selected patient, arytenoid adduction is an important adjunct.

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