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Injection Laryngoplasty

Injection laryngoplasty is a procedure during which the vocal cord is injected (filled) with an implant material. The most common reason for this is a paralyzed vocal cord, but it might also be used for severe vocal cord bowing unresponsive to voice building. There are also other diagnoses such as atrophy or tissue loss. In each of these diagnoses, the patient is motivated by a weak, air-wasting (breathy or diplophonic) voice quality that is highly limiting to his or her ability to communicate.

Materials available for injection are: a temporary gel (various brands); a semi-permanent calcium hydroxyapatite paste; micronized human collagen (Cymetra™); the patient’s own fat, usually harvested from around the umbilicus; or in an earlier era, Teflon™ paste.

The particular material used usually depends upon whether temporary or more permanent voice strengthening is needed.

The purpose of injection laryngoplasty is two-fold:

First, to fatten the cord and shift its static position toward the midline so that the other (mobile) vocal cord can “reach it.” The second reason is to fortify the tissue so that the deficient cord is less flaccid and can “stand up” to the air pressure below and passing between the two cords when they are positioned together to create voice.

The vocal cord can be injected in three ways:

  1. With the help of extensive topical anestheisa, in an “office” videoendoscopy room, using a curved cannula inserted through the mouth, over the back of the tongue, and down into the cord through its upper surface.
  2. In an “office” videoendoscopy room, injecting through the anterior neck while viewing the vocal cords video-endoscopically on a monitor screen.
  3. In an outpatient operating room and during brief general anesthesia, viewing through a laryngoscope placed through the mouth to visualize the vocal cords, and injecting in a straight line through the upper surface of the vocal cord(s).

Which method is used depends on surgeon and patient preference, as well as the circumstance. For example, a medically-fragile patient might be best done under topical anesthesia in an “enhanced office” setting.  A person having more permanent material injected, and certainly if it is to be bilateral, may need exquisite symmetry of injection more suitably done under brief general anesthesia.

Injection Laryngoplasty with Temporary Gel

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Laryngoplasty

Laryngoplasty (1 of 4)

This person awakened with a weak, whispery voice after emergency abdominal surgery. Now 3+ months later, voice is returning by degrees but is still very weak. In this photo, the patient is breathing quietly. The weak left vocal cord is more bowed than the right.
whispery air-wasting voice

Reason for air-wasting (2 of 4)

When she tries to produce voice, the left vocal cord comes only part of the way to the midline, leaving a large gap, and explaining her whispery air-wasting voice quality.
Voice gel injected into vocal cord

Voice gel injected into vocal cord (3 of 4)

On the same day, due to pressing patient need, the left vocal cord was “plumped” with voice gel. That material typically provides temporary benefit of 6 to 12 weeks, gradually absorbing during that time.
Vocal cords close completely

Vocal cords close completely (4 of 4)

Voice is dramatically improved, now that her vocal cords can more fully close to reduce the air-wasting and transform the voice from whispery to strong. Compare with photo 2.

Injection Laryngoplasty

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Vocal cord paralysis

Vocal cord paralysis (1 of 7)

This person has a whispery voice due to right vocal cord paralysis. The right cord (left of photo) does not move from this lateralized position, whether she is breathing or attempting to make voice. The left cord (right of photo) is mobile and lateralized in this breathing position but can come to midline (see photo 3) when she makes voice. Here you see a needle poised to inject the slender, paralyzed lateralized cord with a filler material, in this case voice “gel.”
Voice gel injection

Voice gel injection (2 of 7)

After the cord has been plumped up with injected voice gel. The injected cord is now within reach of the left cord during voicing, and it is also more firm.
Strong voice

Success (3 of 7)

The needle is withdrawn, and the patient is producing strong voice.
Plump right vocal cord

Plump right vocal cord (4 of 7)

A month later, as expected, the right cord (left of photo) remains plump.
posterior gap due to LCA weakness

Posterior gap (5 of 7)

Voice remains very good, due to ability to press the cords together. The upper surface of the injected cord is at a higher level than the left cord, due to the expected bulging “superiorly” and not only medially. Incidentally noted is the posterior gap due to LCA weakness. See the tell-tale lateral turning of the right vocal process at arrow.
right cord does not fully lateralize

PCA Weakness (6 of 7)

A little over a year after injection, the right cord appears to remain somewhat plump, as though some voice gel remains in a “pool” that protects from resorption. Though not well shown here, the right cord does not fully lateralize, suggesting residual PCA weakness.
vocal process has come back into line

LCA muscle recovered (7 of 7)

Voice remains very good, and the cords come into good approximation. The upper surface bulging is no longer seen. The most telling finding is that the LCA muscle appears to have recovered, and very likely, the TA muscle with it. Note that the vocal process has come back into line with the rest of the cord (arrow), and the posterior commissure gap seen in photo 5 is no longer seen. The patient’s excellent voice is explained by recovery of voicing muscles (TA and LCA) more than by residual voice gel.
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