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The Effectiveness of Using Laryngeal Electromyography Guidelines for Injection Augmentation—Reply

The Effectiveness of Using Laryngeal Electromyography Guidelines for Injection Augmentation—Reply In Reply I would like to thank Tang and coauthors1 for their comments on our recent article2 and for giving me the opportunity to further clarify our technique. First, they1 express doubt about the usefulness of laryngeal electromyography (LEMG) guidance in a paralyzed vocal fold with absolutely no electrical activity. Actually, this condition rarely occurs because of the strong likelihood of laryngeal reinnervation after recurrent laryngeal nerve injury.3 In an online video published with our article, we show a successful injection in this type of case.2 We also introduced an “airway signal,” characterized with regular waves on LEMG, indicating that the LEMG needle is in the laryngeal airway. During the procedure, if we confirmed that the needle tip was between the airway and thyroid cartilage, a silent electrical signal could also be used as other abnormal signals to locate the paralyzed thyroarytenoid muscle. Second, Tang and coauthors1 emphasize that fillers should be deeply injected into the lateral aspect of the paraglottic muscle complex. However, the buried tip of the needle cannot be seen directly, even under laryngoscopy. Especially for a transcervical submucosa approach, the location of the needle depends on identification of transmitted motion within the vocal fold, which proves difficult.4 Theoretically, a filler in the paraglottic space that could push the vocal fold medially is acceptable, no matter whether the injection is deeper or not. Third, they1 expressed concern about superficial injection, placement of filler in wrong space, and airway safety without visual monitoring. We have emphasized that our technique only proves the safety of injection with hyaluronic acid (HA) that is highly biocompatible with vocal fold tissue. Chan and Titze5 even commented that HA may be a potentially optimal bioimplant for lamina propria deficiencies. Even under laryngoscopy guidance, an unfavorable superficial injection still may occur because of less precise localization of small-bore needle tip. Needles with a larger size may also injure the overlying mucosa or create a “tear” through which the injected filler may seep out.6 Therefore, Chheda et al6 suggested that longer-lasting fillers, such as calcium hydroxylapatite, be injected in the operating room under general anesthesia until the surgeon gains experience with this technique. In our experience, the shape of the overinjected vocal fold with 1 mL of HA will be remodeled in response to the compression from the contralateral mobile vocal fold. Hence, delicate visual monitoring of the HA injection amount and injection site by laryngoscopy will become less important.1Regarding airway patency, we have mentioned that surgeons need to confirm that the contralateral healthy vocal fold can fully abduct before any vocal fold medialization procedure. With this precaution, overinjection of fat under general anesthesia is commonly performed without airway problem. Furthermore, we do not recommend bilateral injection with our technique. Finally, Tang and coauthors1 comment that our technique will take away the surgeon’s ability to judge vertical height, the amount of medialization, and the quality of the glottal wave. However, in the opinion of Isshiki,7 inaccessibility of the intraoperative adjustment and irreversibility during injection is the most notable disadvantage of vocal fold injection and is the reason he developed laryngeal framework surgery. Under laryngoscopy, although we could see the change, we still could not precisely adjust the change during injection. Back to top Article Information Corresponding Author: Chen-Chi Wang, MD, Department of Otolaryngology–Head & Neck Surgery, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd, Taichung 40705, Taiwan (entccwang@msn.com). Conflict of Interest Disclosures: None reported. References 1. Tang CG, Mor N, Blitzer A. The effectiveness of using laryngeal electromyography guidelines for injection augmentation. JAMA Otolaryngol Head Neck Surg. 2015;141(11). doi:10.1001/jamaoto.2015.2416.Google Scholar 2. Wang CC, Chang MH, Jiang RS, et al. Laryngeal electromyography-guided hyaluronic acid vocal fold injection for unilateral vocal fold paralysis: a prospective long-term follow-up outcome report. JAMA Otolaryngol Head Neck Surg. 2015;141(3):264-271.PubMedGoogle ScholarCrossref 3. Woodson GE. Spontaneous laryngeal reinnervation after recurrent laryngeal or vagus nerve injury. Ann Otol Rhinol Laryngol. 2007;116(1):57-65.PubMedGoogle ScholarCrossref 4. Sulica L, Rosen CA, Postma GN, et al. Current practice in injection augmentation of the vocal folds: indications, treatment principles, techniques, and complications. Laryngoscope. 2010;120(2):319-325.PubMedGoogle Scholar 5. Chan RW, Titze IR. Hyaluronic acid (with fibronectin) as a bioimplant for the vocal fold mucosa. Laryngoscope. 1999;109(7 Pt 1):1142-1149.PubMedGoogle ScholarCrossref 6. Chheda NN, Rosen CA, Belafsky PC, Simpson CB, Postma GN. Revision laryngeal surgery for the suboptimal injection of calcium hydroxylapatite. Laryngoscope. 2008;118(12):2260-2263.PubMedGoogle ScholarCrossref 7. Isshiki N. Phonosurgery: Theory and Practice. Tokyo, Japan: Springer-Verlag; 1989. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Otolaryngology - Head & Neck Surgery American Medical Association

The Effectiveness of Using Laryngeal Electromyography Guidelines for Injection Augmentation—Reply

JAMA Otolaryngology - Head & Neck Surgery , Volume 141 (11) – Nov 1, 2015

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Publisher
American Medical Association
Copyright
Copyright © 2015 American Medical Association. All Rights Reserved.
ISSN
2168-6181
eISSN
2168-619X
DOI
10.1001/jamaoto.2015.2416
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Abstract

In Reply I would like to thank Tang and coauthors1 for their comments on our recent article2 and for giving me the opportunity to further clarify our technique. First, they1 express doubt about the usefulness of laryngeal electromyography (LEMG) guidance in a paralyzed vocal fold with absolutely no electrical activity. Actually, this condition rarely occurs because of the strong likelihood of laryngeal reinnervation after recurrent laryngeal nerve injury.3 In an online video published with our article, we show a successful injection in this type of case.2 We also introduced an “airway signal,” characterized with regular waves on LEMG, indicating that the LEMG needle is in the laryngeal airway. During the procedure, if we confirmed that the needle tip was between the airway and thyroid cartilage, a silent electrical signal could also be used as other abnormal signals to locate the paralyzed thyroarytenoid muscle. Second, Tang and coauthors1 emphasize that fillers should be deeply injected into the lateral aspect of the paraglottic muscle complex. However, the buried tip of the needle cannot be seen directly, even under laryngoscopy. Especially for a transcervical submucosa approach, the location of the needle depends on identification of transmitted motion within the vocal fold, which proves difficult.4 Theoretically, a filler in the paraglottic space that could push the vocal fold medially is acceptable, no matter whether the injection is deeper or not. Third, they1 expressed concern about superficial injection, placement of filler in wrong space, and airway safety without visual monitoring. We have emphasized that our technique only proves the safety of injection with hyaluronic acid (HA) that is highly biocompatible with vocal fold tissue. Chan and Titze5 even commented that HA may be a potentially optimal bioimplant for lamina propria deficiencies. Even under laryngoscopy guidance, an unfavorable superficial injection still may occur because of less precise localization of small-bore needle tip. Needles with a larger size may also injure the overlying mucosa or create a “tear” through which the injected filler may seep out.6 Therefore, Chheda et al6 suggested that longer-lasting fillers, such as calcium hydroxylapatite, be injected in the operating room under general anesthesia until the surgeon gains experience with this technique. In our experience, the shape of the overinjected vocal fold with 1 mL of HA will be remodeled in response to the compression from the contralateral mobile vocal fold. Hence, delicate visual monitoring of the HA injection amount and injection site by laryngoscopy will become less important.1Regarding airway patency, we have mentioned that surgeons need to confirm that the contralateral healthy vocal fold can fully abduct before any vocal fold medialization procedure. With this precaution, overinjection of fat under general anesthesia is commonly performed without airway problem. Furthermore, we do not recommend bilateral injection with our technique. Finally, Tang and coauthors1 comment that our technique will take away the surgeon’s ability to judge vertical height, the amount of medialization, and the quality of the glottal wave. However, in the opinion of Isshiki,7 inaccessibility of the intraoperative adjustment and irreversibility during injection is the most notable disadvantage of vocal fold injection and is the reason he developed laryngeal framework surgery. Under laryngoscopy, although we could see the change, we still could not precisely adjust the change during injection. Back to top Article Information Corresponding Author: Chen-Chi Wang, MD, Department of Otolaryngology–Head & Neck Surgery, Taichung Veterans General Hospital, No. 1650, Sec. 4, Taiwan Blvd, Taichung 40705, Taiwan (entccwang@msn.com). Conflict of Interest Disclosures: None reported. References 1. Tang CG, Mor N, Blitzer A. The effectiveness of using laryngeal electromyography guidelines for injection augmentation. JAMA Otolaryngol Head Neck Surg. 2015;141(11). doi:10.1001/jamaoto.2015.2416.Google Scholar 2. Wang CC, Chang MH, Jiang RS, et al. Laryngeal electromyography-guided hyaluronic acid vocal fold injection for unilateral vocal fold paralysis: a prospective long-term follow-up outcome report. JAMA Otolaryngol Head Neck Surg. 2015;141(3):264-271.PubMedGoogle ScholarCrossref 3. Woodson GE. Spontaneous laryngeal reinnervation after recurrent laryngeal or vagus nerve injury. Ann Otol Rhinol Laryngol. 2007;116(1):57-65.PubMedGoogle ScholarCrossref 4. Sulica L, Rosen CA, Postma GN, et al. Current practice in injection augmentation of the vocal folds: indications, treatment principles, techniques, and complications. Laryngoscope. 2010;120(2):319-325.PubMedGoogle Scholar 5. Chan RW, Titze IR. Hyaluronic acid (with fibronectin) as a bioimplant for the vocal fold mucosa. Laryngoscope. 1999;109(7 Pt 1):1142-1149.PubMedGoogle ScholarCrossref 6. Chheda NN, Rosen CA, Belafsky PC, Simpson CB, Postma GN. Revision laryngeal surgery for the suboptimal injection of calcium hydroxylapatite. Laryngoscope. 2008;118(12):2260-2263.PubMedGoogle ScholarCrossref 7. Isshiki N. Phonosurgery: Theory and Practice. Tokyo, Japan: Springer-Verlag; 1989.

Journal

JAMA Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: Nov 1, 2015

References