Effect of injection augmentation on need for framework surgery in unilateral vocal fold paralysis

Abstract

Objective To determine whether injection augmentation reduces the likelihood of ultimately needing definitive framework surgery in unilateral vocal fold paralysis (UVFP) patients. Study Design Retrospective cohort study Methods All patients diagnosed with UVFP (2008–2012) at the academic center were identified. Time from symptom onset to presentation to either a community otolaryngologist and/or academic center as well as any directed treatment(s) were recorded. Stepwise, multivariate logistic regression analysis was used to determine whether injection augmentation independently affected odds of needing definitive, framework surgery among patients seen within nine months of symptom onset and who had not undergone any prior rehabilitative procedures. Results Cohort consisted of 633 patients (55% female, 80% Caucasian, median age 60 years) with UVFP. The majority of etiologies were either surgery (48%) or idiopathic (37%). Duration to presentation at community otolaryngologist was shorter than to the academic center (median 2 vs. 6 months). Overall, less than half of UVFP patients had any operation (46%). Multivariate logistic regression found that earlier injection augmentation did not affect odds of ultimately undergoing framework surgery (OR 1.13, CI 0.92 – 1.40; p=0.23). Conclusion Nearly half of UVFP patients do not require any rehabilitative procedure. When indicated, early injection augmentation is effective at temporarily alleviating associated symptoms, but does not reduce likelihood of needing a definitive framework operation in patients with UVFP. Understanding practice patterns and fostering early detection and treatment may improve quality of life in this patient population.

Time course of recovery of idiopathic vocal fold paralysis

“…The recovered group was somewhat more likely to have undergone injection augmentation, an intervention considered to improve outcome in early observations after the widespread adoption of office injection yielded increased numbers of patients to study . Subsequent work by Francis et al revealed this to be an artifact of time to presentation: injection augmentation was simply more likely to be used in patients presenting soon after onset, and thus more likely to recover than patients later in the course of their vocal fold paralysis . The population in this study appears to reflect the same bias.…”

Long‐term outcomes in unilateral vocal fold paralysis patients

“…These results suggest that early IL with an agent designed to have a temporary duration of action may result in sustained improvement in glottic competence and perceptual voice in a certain cohort of patients. Although our group and others have previously demonstrated an association between IL and decreased rates of subsequent PM, a recent retrospective study by Francis et al found that IL had no effect on the need for definitive framework surgery in a cohort of 633 patients . This study is important in that it cautions readers to consider selection bias when interpreting the association between IL and need for subsequent PM procedures, given that many patients with UVFP may achieve spontaneous recovery of vocal fold function despite intervention.…”

“…Furthermore, a recent study has suggested that these lower rates of PM in patients who undergo early IL with a temporary agent are associated with improved measures of glottic competence as judged by videolaryngostroboscopic assessments of glottic closure in addition to improved perceptual evaluations of voice . Contrary to these findings, others have found that early IL has no effect on the ultimate rate of PM in patients who present early (<9 months) from symptom onset . Although there remains the question as to whether early IL can obviate the need for subsequent PM in certain patient cohorts, less is known regarding long‐term outcome measures among those patients who undergo IL with a temporary agent only and those who receive a PM procedure.…”

“…4 Contrary to these findings, others have found that early IL has no effect on the ultimate rate of PM in patients who present early (<9 months) from symptom onset. 5 Although there remains the question as to whether early IL can obviate the need for subsequent PM in certain patient cohorts, less is known regarding long-term outcome measures among those patients who undergo IL with a temporary agent only and those who receive a PM procedure. Herein, we describe long-term outcomes for patients who received upfront IL with a temporary agent for a diagnosis of UVFP as compared with those patients who received conservative management alone or who subsequently required PM.…”

“…Contrary to these findings, a recent retrospective cohort study by Francis et al found that early IL did not affect the odds of ultimately needing open framework surgery in patients with UVFP who presented within 9 months of symptoms onset. 5 Despite conflicting evidence on the role of early IL and the subsequent need for PM, still less is known regarding how patients who receive early IL with a temporary agent compare to those individuals who undergo PM, either as initial treatment or as subsequent therapy. The purpose of this study, therefore, was to compare objective outcomes of glottic competence among those patients who underwent IL alone versus those patients who underwent CM or PM for UVFP.…”