I. GENERAL CONSIDERATIONS

A. Indications

1. Symptomatic glottic insufficiency

a. Laryngeal paralysis or laryngeal paresis in patient whose recovery of vocal cord mobility is uncertain

b. Glottic insufficiency with mobile vocal folds (ie, presbylaryngis)

2. Symptoms: dysphonia, dysphagia, poor cough

B. Contraindications

1. Inability to perform direct laryngoscopy

a. Unstable cervical spine

b. Unable to obtain exposure of the larynx (ie, retrognathic)

2. May consider other approaches

a. Percutaneous injection through cricothyroid membrane (see Laryngeal fat injection protocol)

b. Transoral injection employing indirect mirror exposure of larynx

II. PREOPERATIVE PREPARATION

A. Evaluation

1. Essential for most cases

a. Speech pathology assessment (see Laryngeal diagnostics protocol)

b. Videolaryngoscopy with voice recording (see Videostroboscopy protocol)

2. Consider for selected cases

a. Trial of voice therapy

b. Laryngeal electromyography (see Laryngeal EMG protocol)

3. With history of neck arthritis or neck surgery/injury, lateral neck radiographs inflexion and extension

4. Offer to most patients with dentition dental prosthetics evaluation preoperatively to fashion a tailored (custom-made) acrylic dental splint

a. To prevent dental injury more effectively than can the standard plastic “gump”

b. To patients with difficult exposure in whom the acrylic guard will permit a greater degree of force applied to dentition through “fulcrum laryngoscopy” (see suggested reading Dental Protection During Rigid Endoscopy)

B. Consent

1. Describe procedure and expected recovery

a. Identify that the Gelfoam provides temporary (2 months) medialization for most

b. Identify that voice quality will evolve after Gelfoam placement

2. Potential complications

a. Bleeding, infection, reaction to anesthetic

b. Damage to adjacent structures

(1) Lips, teeth, tongue, larynx from direct laryngoscopy

(2) Hoarseness, airway obstruction, continued dysphagia with aspiration

III. NURSING CONSIDERATIONS

A. Room Setup

1. See Endoscopy Room Setup

a. Iowa modified suspension

b. Audio-visual unit

c. Microscope with a 400 lens

B. Instrumentation and Equipment

1. Standard

a. Arnold Bruening intraoral injection tray

b. Direct laryngoscope tray

2. Special

a. Bronchoscopy tray, adult

b. Freche monopolar instrument tray

c. Laryngoscope instrument tray, microscopic direct

d. Lewy laryngoscope holder tray

e. Ossof-Karlin laryngoscope instrument tray

f. Tracheotomy tray

g. Neurosurgical cottonoids, 1/2 in x 1/2 in

h. Storz fiber optic light cable

i. Storz telescope, straight forward 0°, 5 mm x 6 7/8 in

C. Medications (specific to nursing)

1. Gelfoam powder, 1 g

2. Sodium chloride, 0.9%, preservative-free, 10 cc (use 4 cc to mix with Gelfoam)

3. 2% lidocaine

D. Prep and Drape

1. No prep

2. Drape

a. Head drape

b. Split sheet

E. Drains and Dressings

None

F. Special Considerations

1. Instrumentation should be set up prior to induction

2. Tracheotomy tray and supplies should be available for an emergency tracheotomy

3. Bruening syringe with 22-gauge needle (with a backup syringe in case of malfunction)

4. Mix the Gelfoam powder (1 gm) with 4 cc of sterile saline in a sterile specimen container

5. 2% lidocaine in syringe with 25-gauge needle to apply to topically laryngeal surface through laryngoscope after Gelfoam injection to reduce chance of laryngospasm

IV. ANESTHETIC CONSIDERATIONS

A. General Anesthesia

1. Communication with anesthesia staff essential

a. Oral endotracheal intubation with small (5.5 to 6.0) endotracheal tube (MLT tube = microlaryngeal/tracheal tube)

b. Short-term paralysis (estimate 5-minute case)

c. Consideration for alternative methods

(1) Jet anesthesia

(2) Apnea

(3) Local anesthesia with sedation (see Local anesthesia for rigid endoscopy protocol)

B. Preoperative Systemic Medications

1. Glycopyrrolate 0.1 to 0.2 mg IM on call to operating room

a. The drying effect improves exposure; consider avoiding in patients with xerostomia

b. Vagolytic effect

2. Consider Decadron 8 to 10 mg IV when IV started to diminish edema. Contraindications: diabetes, ulcer disease, other

3. Antistaphylococcal antibiotics preoperatively and for 5 days postoperatively

C. Positioning

1. May be done with head toward anesthesia or rotated 90°

2. Head of bed elevated 15° to 30°, neck extended with shoulder roll

V. OPERATIVE PROCEDURE

A. Expose larynx, usually with Dedo laryngoscope.

B. Do not use microscope (it gets in the way).

1. Consider using rigid telescope connected to video equipment to photograph vocal folds; this exposure permits the injection to be done with full imaging (best for teaching purposes).

2. Alternatively, inject through laryngoscope under direct vision.

C. Employ 22-gauge needle without guard (although guarded tip helps to prevent excessively deep injection into the subglottis, it also precludes full view of the needle tip as it is inserted).

D. Expose vocal folds with tip of laryngoscope at least 3 mm above the anterior commissure to avoid distorting glottis.

E. Load Gelfoam into a Luer Lock syringe, rotate end of syringe containin lfoam onto the proximal end of the Bruening syringe barrel to fill with Gelfoam and assemble Bruening syringe.

F. Injection

1. First injection

a. Midway between tip of vocal process and anterior commissure at the point of maximum concavity as determined by preoperative and intraoperative assessment

b. Use lateral aspect of needle to push false cord laterally and inject deeply into the paraglottic space medial to ventricle

2. Second injection

a. Immediately lateral to vocal process of arytenoid

b. Designed to rotate vocal process medially, not always successful

3. Employing large upbiting forceps with the tips closed. Manipulate bolus of Gelfoam in the vocal fold from dorsal direct and medial direction to provide smooth contour to vocal fold

G. Spray the vocal folds and supraglottis with 2 to 4 cc of 2% lidocaine.

VI. POSTOPERATIVE CARE

A. Procedure is usually done as outpatient

1. If there is any question about adequacy of the airway, plan overnight observation in hospital.

2. Consider evaluating larynx with indirect mirror examination or flexible fiber optic laryngoscope before discharge.

B. Begin oral feedings when alert.

If dysphagia with aspiration was an important component of the symptoms preoperatively, consider evaluating with a “cookie swallow” (OPMS) before feeding.

C. Continue oral antibiotics for 5 to 7 days.

D. Voice rest

1. Absolute for 48 hours

2. Relative for 2 weeks: employ arm’s length rule wherein the patient does not addess a person unless they are within arm’s length.

E. Follow-up individualized based on symptoms

1. If dysphagia is a significant component, consider “cookie swallow” postoperative day 1.

2. If voice is only concern, then follow up in 2 weeks; with videostroboscopic exam 6 weeks postoperatively.

VII. CPT CODING

A. 31570, Laryngoscopy, direct, with injection into vocal cord(s), therapeutic

B. 31570, Laryngoscopy, direct, with injection into vocal cord(s), with operating microscope

VIII. SUGGESTED READING

A. Hoffman HT, Winters P, Sullivan MS. Gelfoam injection for vocal cord paralysis prior to radiation therapy. Ear Nose Throat J. 1991;70:385-386.

B. Lewy RB.Teflon injection: pointers and pitfalls. Ann Otol Rhinol Laryngol. 1993;102:282-283.

C. Montgomery WW. Laryngeal paralysis: Teflon injection. Ann Otol. 1979;8:647-657.

D. Olsen GT, Moreano EH, Arcuri MR, Hoffman HT. Dental protection during rigid endoscopy. Laryngoscope. 1995;105:662-663.

E. Schramm VL, Lavorato AS.: Gelfoam paste injection for vocal cord paralysis: temporary rehabilitation of glottic incompetence. Laryngoscope. 1978;88.1268-1273.