Eur Arch Otorhinolaryngol (2014) 271:3095–3099 DOI 10.1007/s00405-014-3257-2
SHORT COMMUNICATION
Day surgery for vocal fold lesions using a double-bent 60-mm Cathelin needle Fumimasa Toyomura • Ryoji Tokashiki • Hiroyuki Hiramatsu Kiyoaki Tsukahara • Ray Motohashi • Eriko Sakurai • Masaki Nomoto • Mamoru Suzuki
•
Received: 23 May 2014 / Accepted: 26 August 2014 / Published online: 2 September 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Day surgery for vocal cord lesions overcomes the disadvantages of laryngomicrosurgery under general anesthesia. We present our experience with treatment of vocal fold lesions using a long double-bend Cathelin needle that can access all parts of the vocal cords. A 23G, 60-mm-long Cathelin needle was bent twice by 45o at a distance of 1 and 2 cm from the tip, and was attached to a syringe. Under topical anesthesia and nasal endoscopy of the laryngopharynx, the needle was inserted percutaneously perpendicular to the skin, the direction of insertion being altered when the bends in the needle reached the skin surface. This allows the tip of the needle to access all parts of the glottis, allowing the performance of procedures such as biopsies, excision of lesions, and injection into the vocal folds. Between January 2011 and December 2013, we used this technique to perform vocal fold procedures in 566 patients presenting for treatment of spasmodic dysphonia (412 cases, 73 %) and other vocal fold lesions. Only minor complications, such as hematoma (3 patients, 0.5 %) and slight bleeding from the puncture site in the epiglottic vallecula (all patients, 100 %), which ceased spontaneously within 10 min, were seen. Erroneous puncture occurred in F. Toyomura (&) R. Tokashiki H. Hiramatsu R. Motohashi E. Sakurai M. Nomoto M. Suzuki Department of Otolaryngology, Tokyo Medical University, 1-6-7 Nishishinjuku Shinjuku-ku, Tokyo, Japan e-mail: [email protected] F. Toyomura R. Tokashiki Shinjuku Voice Clinic, 1-6-7 Nishishinjuku Shinjuku-ku, Tokyo, Japan K. Tsukahara Otorhinolaryngology, Head and Neck Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachiouji City, Tokyo, Japan
three patients (0.5 %) and the puncture had to be repeated in 38 patients (6.7 %). The procedure was completed successfully in all cases (100 %). Surgery for vocal fold lesions under topical anesthesia using our double-bend Cathelin needle technique is simple, safe, and useful. Keywords Injection laryngoplasty Cathelin needle Thyrohyoid approach Topical anesthesia Day surgery
Introduction Laryngomicrosurgery under general anesthesia is the usual surgical method for treating vocal fold lesions. For the patient, this method involves burdens in the form of the cost of hospitalization and the time required for the surgery. Moreover, general anesthesia presents the risk of complications. On the other hand, day surgery of the larynx does not require hospitalization, making it possible to reduce the treatment costs borne by the patient. Since general anesthesia is not required, the risk of complications due to such anesthesia is lowered. Surgery on elderly patients and patients with comorbidities is also possible. Day surgery, performed using topical anesthesia applied to the larynx, with the patient in a state of wakefulness, has been tried by various groups, mainly for intra-vocal fold injection [1–7]. Injection of fat or collagen has been performed to prevent vocal fold paralysis and atrophy, while injection of botulinum toxin under electromyogram (EMG) control, etc., has been performed to prevent spasmodic dysphonia. Performance of day surgery for vocal fold lesions in the outpatient clinic is usually carried out perorally using a laryngeal injection needle, although injection material is wasted, because the needle is thick (19G) and long [1]. Moreover, with peroral methods, even when topical anesthesia is administered carefully, there are patients in
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whom the surgery cannot be completed due to activation of the gag reflex [1]. In terms of the approach to the larynx, some surgeons have approached the glottis using percutaneous insertion of an injection needle [2, 4–7]. For this, the needle is inserted percutaneously via the cricothyroid or thyrohyoid membranes, and injection into the vocal folds is performed when the needle reaches the glottis. In the case of injection via the cricothyroid membrane, the puncture is performed so that the needle tip does not enter the airway, precluding occurrence of reflex reactions, such as coughing. However, since the approach is from the subglottis, direct confirmation of the target site is difficult. Thus, EMG may be required to confirm that the needle has actually reached the thyroarytenoid muscle, which is the target [2]. On the other hand, in the case of the thyrohyoid approach (THA), the surgery can be carried out while observing the needle tip with an endoscope, making this a very useful method. However, injection anterior to the center of the vocal folds is difficult [4, 5], and it is not unusual for it to be impossible to perform the injection [5, 6]; hence, this approach has not really gained popularity. We have been performing day surgery with topical anesthesia of the larynx using the THA, for which we use a 60-mm, 23G Cathelin needle (Terumo Corp., Tokyo, Japan) with a double-bend at its tip (double-bent 60-mm Cathelin Needle: DBCN). The DBCN is useful, not only because it permits full access to the vocal folds, anteriorly, posteriorly, laterally and medially, but also because it can be applied to surgeries not involving injection, since the needle tip can also be used for incisions. This method was approved by our ethical review board.
Eur Arch Otorhinolaryngol (2014) 271:3095–3099
4 % lidocaine is topically applied to the laryngopharynx. We observe the laryngopharynx using the 4-mm-diameter endoscope with a forceps port, inject 4 % lidocaine via the forceps port and disperse it in the laryngopharynx. After dispersing lidocaine in the laryngopharynx several times, the adequacy of the anesthetic effect is confirmed. DBCN puncture The patient is instructed to tilt his/her head backwards, so that the thyroid cartilage can be readily observed. Our procedure can be performed only one surgeon. We control endoscope for observing larynx in the left hand then, we control DBCN in right hand (Fig. 2). While observing the larynx with an endoscope, the superior thyroid notch is palpated to accurately determine its position. The DBCN is inserted 0.5–1.0 cm above the notch (Fig. 2). First, the tip of the needle is inserted so that it is perpendicular to the skin of the neck. The DBCN is then inserted up to the point of its first bend; next, when the needle pierces the epithelium and the thyrohyoid membrane, its tip is directed 90° downward and it is advanced so that it penetrates the larynx perpendicularly (Fig. 3). At this point, endoscopic observation can confirm the accuracy of the puncture and how the needle tip exits the laryngeal vestibule. After the needle tip exits the vestibule of the epiglottis, the needle is advanced until the point of the second bend of the DBCN exits the glottic area. At this time, the tip of the needle is inserted past the glottis to the subglottis (Fig. 4). When the needle has penetrated as far as the subglottis, its mobility improves and it becomes easier to perform surgical manipulations. Next, the position of the needle tip is
Surgical preparation and methods Preparation of the DBCN A 60-mm, 23G Cathelin needle is bent about 45° by hand at each of two sites, approximately 1 and 2 cm from the needle tip (Fig. 1). The DBCN is then attached to a syringe that differs depending on the surgery to be performed: a syringe containing the substance to be injected in the case of an injection, and a 1-mL syringe to be used as a handle when performing procedures, such as incision. Termo Co states that the needle never be broken, if it is bent 90° with 5 mm radius of curvature. The statement is warranted by Japanese Industrial Standards (JIS). As the radius is more than 5 mm and angle is less than 90° in our procedure, the method is considered to be safe. Anesthesia The surgery is performed as an outpatient procedure, with the patient in the seated position. Prior to surgery,
123
Fig. 1 A 60-mm, 23G Cathelin needle is manually bent by about 45° at each of two sites, approximately 1 and 2 cm from the needle tip. The distance is changeable from 1.0 to 1.5 cm due to the size of larynx
Eur Arch Otorhinolaryngol (2014) 271:3095–3099
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Fig. 4 DBCN reachs all positions around the glottis
Operative method Fig. 2 While observing the larynx with an endoscope inserted through the nose, the superior thyroid notch is palpated to accurately determine its position. The double-bend Cathelin needle is inserted 0.5–1.0 cm above the notch
Fig. 3 The tip of the double-bent Cathelin needle is inserted so that it is perpendicular to the skin of the neck. The DBCN is next inserted up to the point of its first bend; then, when the needle pierces the epithelium and the thyrohyoid membrane, its tip is directed 90° downward and it is advanced so that it penetrates the larynx perpendicularly
adjusted to fit the objective of the surgery. Using the 60-mm Cathelin needle, which is longer than an ordinary needle, surgical manipulations can be performed at all positions around the glottis, i.e., anteriorly, posteriorly and laterally (Fig. 4–ˆ).
Day surgery for vocal fold lesions using the DBCN We use the operative method described above to perform incision operations for vocal fold lesions, such as nodules, polyps and cysts, under topical anesthesia. For vocal fold nodules and polyps, we incise the base of the lesion with the tip of the DBCN, and after separating it from the vocal fold, we excise the lesion using a biopsy forceps that we insert via an endoscope having a forceps port. For vocal fold cysts, we incise the cyst wall with the tip of the DBCN and drain the fluid contents of the cyst. The incision is enlarged, cutting the upper portion of the cyst wall, spanning the entire cyst, and including the vocal fold mucosa. After draining the fluid contents, we insert one cup of the biopsy forceps that is inserted via the forceps port of the endoscope into the cyst, and insert the other cup so that it comes around the outside of the cyst wall, following which we remove a portion of the cyst wall. Figure 5 demonstrates incision of a large vocal fold cyst using the tip of the DBCN. Figure 6 shows incision of the surface of a vocal fold nodule. Injection using the DBCN The 60-mm Cathelin needle that we use reaches all sites of the vocal folds, including anteriorly, posteriorly and laterally, and its good mobility enables surgical manipulations. Thus, with a single puncture, surgical procedures can be performed on the vocal folds bilaterally. With good visualization, it is possible to accurately inject substances into the target site: hyaluronic acid into Reinke’s space to prevent vocal fold atrophy and botulinum toxin into the thyroarytenoid muscle to prevent spasmodic dysphonia.
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Eur Arch Otorhinolaryngol (2014) 271:3095–3099
vocal fold paralysis in 30 cases (5 %) and vocal fold atrophy in 45 cases (8 %). Complications Minor hematoma at the front of the neck was seen in three patients (0.5 %). In all patients, slight bleeding from the epiglottic vallecula occurred at the puncture site, which also stopped spontaneously within 10 min in all cases. Erroneous puncture of the cricothyroid membrane occurred in three patients (0.5 %), and the puncture step had to be repeated in 38 patients (6.7 %) because the initial site was not optimal. There were no serious complications. The planned surgical procedure was completed in all (100 %) of the patients who underwent surgery. Fig. 5 Incision of a large vocal fold cyst
Discussion
Fig. 6 Incision of the surface of a vocal fold nodule
Surgical results Cases From January 2011 through December 2013, we used the DBCN to perform day surgeries on 566 patients at our facility. Topical anesthesia was given and the patients were in a state of wakefulness during the surgeries. Operations were performed for vocal fold polyps in 34 cases (6 %), vocal fold nodules in 21 cases (4 %), vocal fold cysts in 24 cases (4 %), spasmodic dysphonia in 412 cases (73 %),
123
While laryngomicrosurgery under general anesthesia is the most common surgical method for treating vocal fold lesions, such as polyps and nodules, day surgery using local anesthesia has also been tried, with surgical results similar to those with laryngomicrosurgery under general anesthesia. Laryngomicrosurgery under general anesthesia requires hospitalization of the patient and is burdensome to the patient in terms of cost and hospitalization time. General anesthesia itself is associated with the risk of complications, besides which the surgery can be difficult in elderly patients with decreased cardiopulmonary function or a history of disease of other vital organs. On the other hand, day surgery for vocal fold lesions performed using topical anesthesia does not require hospitalization, reducing the burdens of surgical cost and treatment time on the patient. Resection of vocal fold lesions under topical anesthesia on an outpatient basis is usually performed by peroral excision using special forceps while observing the glottis by laryngeal fiberscopy [8]. However, this method can readily induce the gag reflex and cause pain, such that the surgery is difficult to complete in patients who react strongly; completion is impossible in about 10 % of patients. With the method we have reported here, no tools have to be inserted perorally, making interruption of the procedure due to stimulation of the gag reflex rare. None of the 566 operations we performed on patients from 2011 to 2013 had to be abandoned due to activation of the gag reflex. Similarly, vocal fold injection procedures have been attempted in patients in the awake state and using topical anesthesia, by a method in which the injection materials were injected into the vocal folds perorally using a laryngeal injection needle [2]. However, the gag reflex sometimes interferes with this procedure, as well. Further,
Eur Arch Otorhinolaryngol (2014) 271:3095–3099
about 0.5 mL of injection material remains in the laryngeal injection needle and is, thus, wasted. In cases in which an expensive injection material, such as hyaluronic acid or hydroxyapatite, is used, the financial burden on the medical facility, and thus, the patient, increases. Moreover, the size of a laryngeal injection needle is 19G, as a result of which the injected material readily leaks out of the puncture site. In our method, we use a 23G needle, and although leakage occurs with this needle as well, the amount is less since the puncture site is smaller due to the narrow gauge of the needle. Vocal fold injection performed by THA under topical anesthesia was first reported by Amin in 2006 [4]. However, the injection needle, used in Amin’s method, was an ordinary straight needle, so it could not be inserted into some target sites depending on the angle [5, 6]. Achkar et al. [7] tested vocal fold injection using a 38-mm, 25G needle that was bent 45° at its base and also 45° at 1 cm from its tip. However, in Achkar’s method, as well, the needle was not long enough, meaning that the tip of the needle could not reach the target site in patients with a large larynx. On the other hand, our method DBCN use long needle which is enough to reach any size larynx. So we can reach all sites of the vocal folds bilaterally, including anteriorly, posteriorly and laterally, enabling surgical manipulations at all target sites.
Conclusions The DBCN reported here for treatment of vocal fold lesions can be performed on an outpatient, day-surgery basis, and as a result, it reduces the physical and financial burden on patients. Also, the DBCN avoids triggering the gag reflex, which is an issue in patients undergoing
3099
laryngeal surgery using conventional methods. Moreover, vocal fold injection can be accomplished using a lesser volume of expensive injection materials compared with conventional injection. This latter point is advantageous in that it reduces the financial strain on medical facilities. Acknowledgments No funding or grants were received for this work. This method is approved in an Ethical Review Board of Tokyo Medical University.
References 1. Tateya I, Omori K, Kojima H, Hirano S, Kaneko K, Ito J (2004) Steroid injection to vocal nodules using fiberoptic laryngeal surgery under topical anesthesia. Eur Arch Otorhinolaryngol 261:489–492 2. Wang CC, Chang MH, Wang CP, Liu SA, Liang KL, Wu SH, Jiang RS, Huang HT, Lai HC (2012) Laryngeal electromyographyguided hyaluronic acid vocal fold injection for unilateral vocal fold paralysis—preliminary results. J Voice 26(4):506–514 3. Hirano S, Tateya I, Kishimoto Y, Kanemaru S, Ito J (2012) Clinical trial of regeneration of aged vocal folds with growth factor therapy. Laryngoscope 122:327–331 4. Amin MR (2006) Thyrohyoid approach for vocal fold augmentation. Ann Otol Rhinol Laryngol 115:699–702 5. Sulica L, Rosen CA, Postma GN, Simpson B, Amin M, Courey M, Merati A (2010) Current practice in injection augmentation of the vocal folds: indications, treatment principles, techniques, and complications. Laryngoscope 120:319–325 6. Rees CJ, Mouadeb DA, Belafsky PC (2008) Thyrohyoid vocal fold augmentation with calcium hydroxyapatite. Otolaryngol Head Neck Surg 138:743–746 7. Achkar J, Song P, Andrus J, Franco R Jr (2012) Double-bend needle modification for transthyrohyoid vocal fold injection. Laryngoscope 122:865–867 8. Omori K, Shinohara K, Tsuji T, Kojima H (2000) Videoendoscopic laryngeal surgery. Ann Otol Rhinol Laryngol 109(2): 149–155
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SHORT COMMUNICATION
Day surgery for vocal fold lesions using a double-bent 60-mm Cathelin needle Fumimasa Toyomura • Ryoji Tokashiki • Hiroyuki Hiramatsu Kiyoaki Tsukahara • Ray Motohashi • Eriko Sakurai • Masaki Nomoto • Mamoru Suzuki
•
Received: 23 May 2014 / Accepted: 26 August 2014 / Published online: 2 September 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Day surgery for vocal cord lesions overcomes the disadvantages of laryngomicrosurgery under general anesthesia. We present our experience with treatment of vocal fold lesions using a long double-bend Cathelin needle that can access all parts of the vocal cords. A 23G, 60-mm-long Cathelin needle was bent twice by 45o at a distance of 1 and 2 cm from the tip, and was attached to a syringe. Under topical anesthesia and nasal endoscopy of the laryngopharynx, the needle was inserted percutaneously perpendicular to the skin, the direction of insertion being altered when the bends in the needle reached the skin surface. This allows the tip of the needle to access all parts of the glottis, allowing the performance of procedures such as biopsies, excision of lesions, and injection into the vocal folds. Between January 2011 and December 2013, we used this technique to perform vocal fold procedures in 566 patients presenting for treatment of spasmodic dysphonia (412 cases, 73 %) and other vocal fold lesions. Only minor complications, such as hematoma (3 patients, 0.5 %) and slight bleeding from the puncture site in the epiglottic vallecula (all patients, 100 %), which ceased spontaneously within 10 min, were seen. Erroneous puncture occurred in F. Toyomura (&) R. Tokashiki H. Hiramatsu R. Motohashi E. Sakurai M. Nomoto M. Suzuki Department of Otolaryngology, Tokyo Medical University, 1-6-7 Nishishinjuku Shinjuku-ku, Tokyo, Japan e-mail: [email protected] F. Toyomura R. Tokashiki Shinjuku Voice Clinic, 1-6-7 Nishishinjuku Shinjuku-ku, Tokyo, Japan K. Tsukahara Otorhinolaryngology, Head and Neck Surgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi Hachiouji City, Tokyo, Japan
three patients (0.5 %) and the puncture had to be repeated in 38 patients (6.7 %). The procedure was completed successfully in all cases (100 %). Surgery for vocal fold lesions under topical anesthesia using our double-bend Cathelin needle technique is simple, safe, and useful. Keywords Injection laryngoplasty Cathelin needle Thyrohyoid approach Topical anesthesia Day surgery
Introduction Laryngomicrosurgery under general anesthesia is the usual surgical method for treating vocal fold lesions. For the patient, this method involves burdens in the form of the cost of hospitalization and the time required for the surgery. Moreover, general anesthesia presents the risk of complications. On the other hand, day surgery of the larynx does not require hospitalization, making it possible to reduce the treatment costs borne by the patient. Since general anesthesia is not required, the risk of complications due to such anesthesia is lowered. Surgery on elderly patients and patients with comorbidities is also possible. Day surgery, performed using topical anesthesia applied to the larynx, with the patient in a state of wakefulness, has been tried by various groups, mainly for intra-vocal fold injection [1–7]. Injection of fat or collagen has been performed to prevent vocal fold paralysis and atrophy, while injection of botulinum toxin under electromyogram (EMG) control, etc., has been performed to prevent spasmodic dysphonia. Performance of day surgery for vocal fold lesions in the outpatient clinic is usually carried out perorally using a laryngeal injection needle, although injection material is wasted, because the needle is thick (19G) and long [1]. Moreover, with peroral methods, even when topical anesthesia is administered carefully, there are patients in
123
3096
whom the surgery cannot be completed due to activation of the gag reflex [1]. In terms of the approach to the larynx, some surgeons have approached the glottis using percutaneous insertion of an injection needle [2, 4–7]. For this, the needle is inserted percutaneously via the cricothyroid or thyrohyoid membranes, and injection into the vocal folds is performed when the needle reaches the glottis. In the case of injection via the cricothyroid membrane, the puncture is performed so that the needle tip does not enter the airway, precluding occurrence of reflex reactions, such as coughing. However, since the approach is from the subglottis, direct confirmation of the target site is difficult. Thus, EMG may be required to confirm that the needle has actually reached the thyroarytenoid muscle, which is the target [2]. On the other hand, in the case of the thyrohyoid approach (THA), the surgery can be carried out while observing the needle tip with an endoscope, making this a very useful method. However, injection anterior to the center of the vocal folds is difficult [4, 5], and it is not unusual for it to be impossible to perform the injection [5, 6]; hence, this approach has not really gained popularity. We have been performing day surgery with topical anesthesia of the larynx using the THA, for which we use a 60-mm, 23G Cathelin needle (Terumo Corp., Tokyo, Japan) with a double-bend at its tip (double-bent 60-mm Cathelin Needle: DBCN). The DBCN is useful, not only because it permits full access to the vocal folds, anteriorly, posteriorly, laterally and medially, but also because it can be applied to surgeries not involving injection, since the needle tip can also be used for incisions. This method was approved by our ethical review board.
Eur Arch Otorhinolaryngol (2014) 271:3095–3099
4 % lidocaine is topically applied to the laryngopharynx. We observe the laryngopharynx using the 4-mm-diameter endoscope with a forceps port, inject 4 % lidocaine via the forceps port and disperse it in the laryngopharynx. After dispersing lidocaine in the laryngopharynx several times, the adequacy of the anesthetic effect is confirmed. DBCN puncture The patient is instructed to tilt his/her head backwards, so that the thyroid cartilage can be readily observed. Our procedure can be performed only one surgeon. We control endoscope for observing larynx in the left hand then, we control DBCN in right hand (Fig. 2). While observing the larynx with an endoscope, the superior thyroid notch is palpated to accurately determine its position. The DBCN is inserted 0.5–1.0 cm above the notch (Fig. 2). First, the tip of the needle is inserted so that it is perpendicular to the skin of the neck. The DBCN is then inserted up to the point of its first bend; next, when the needle pierces the epithelium and the thyrohyoid membrane, its tip is directed 90° downward and it is advanced so that it penetrates the larynx perpendicularly (Fig. 3). At this point, endoscopic observation can confirm the accuracy of the puncture and how the needle tip exits the laryngeal vestibule. After the needle tip exits the vestibule of the epiglottis, the needle is advanced until the point of the second bend of the DBCN exits the glottic area. At this time, the tip of the needle is inserted past the glottis to the subglottis (Fig. 4). When the needle has penetrated as far as the subglottis, its mobility improves and it becomes easier to perform surgical manipulations. Next, the position of the needle tip is
Surgical preparation and methods Preparation of the DBCN A 60-mm, 23G Cathelin needle is bent about 45° by hand at each of two sites, approximately 1 and 2 cm from the needle tip (Fig. 1). The DBCN is then attached to a syringe that differs depending on the surgery to be performed: a syringe containing the substance to be injected in the case of an injection, and a 1-mL syringe to be used as a handle when performing procedures, such as incision. Termo Co states that the needle never be broken, if it is bent 90° with 5 mm radius of curvature. The statement is warranted by Japanese Industrial Standards (JIS). As the radius is more than 5 mm and angle is less than 90° in our procedure, the method is considered to be safe. Anesthesia The surgery is performed as an outpatient procedure, with the patient in the seated position. Prior to surgery,
123
Fig. 1 A 60-mm, 23G Cathelin needle is manually bent by about 45° at each of two sites, approximately 1 and 2 cm from the needle tip. The distance is changeable from 1.0 to 1.5 cm due to the size of larynx
Eur Arch Otorhinolaryngol (2014) 271:3095–3099
3097
Fig. 4 DBCN reachs all positions around the glottis
Operative method Fig. 2 While observing the larynx with an endoscope inserted through the nose, the superior thyroid notch is palpated to accurately determine its position. The double-bend Cathelin needle is inserted 0.5–1.0 cm above the notch
Fig. 3 The tip of the double-bent Cathelin needle is inserted so that it is perpendicular to the skin of the neck. The DBCN is next inserted up to the point of its first bend; then, when the needle pierces the epithelium and the thyrohyoid membrane, its tip is directed 90° downward and it is advanced so that it penetrates the larynx perpendicularly
adjusted to fit the objective of the surgery. Using the 60-mm Cathelin needle, which is longer than an ordinary needle, surgical manipulations can be performed at all positions around the glottis, i.e., anteriorly, posteriorly and laterally (Fig. 4–ˆ).
Day surgery for vocal fold lesions using the DBCN We use the operative method described above to perform incision operations for vocal fold lesions, such as nodules, polyps and cysts, under topical anesthesia. For vocal fold nodules and polyps, we incise the base of the lesion with the tip of the DBCN, and after separating it from the vocal fold, we excise the lesion using a biopsy forceps that we insert via an endoscope having a forceps port. For vocal fold cysts, we incise the cyst wall with the tip of the DBCN and drain the fluid contents of the cyst. The incision is enlarged, cutting the upper portion of the cyst wall, spanning the entire cyst, and including the vocal fold mucosa. After draining the fluid contents, we insert one cup of the biopsy forceps that is inserted via the forceps port of the endoscope into the cyst, and insert the other cup so that it comes around the outside of the cyst wall, following which we remove a portion of the cyst wall. Figure 5 demonstrates incision of a large vocal fold cyst using the tip of the DBCN. Figure 6 shows incision of the surface of a vocal fold nodule. Injection using the DBCN The 60-mm Cathelin needle that we use reaches all sites of the vocal folds, including anteriorly, posteriorly and laterally, and its good mobility enables surgical manipulations. Thus, with a single puncture, surgical procedures can be performed on the vocal folds bilaterally. With good visualization, it is possible to accurately inject substances into the target site: hyaluronic acid into Reinke’s space to prevent vocal fold atrophy and botulinum toxin into the thyroarytenoid muscle to prevent spasmodic dysphonia.
123
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Eur Arch Otorhinolaryngol (2014) 271:3095–3099
vocal fold paralysis in 30 cases (5 %) and vocal fold atrophy in 45 cases (8 %). Complications Minor hematoma at the front of the neck was seen in three patients (0.5 %). In all patients, slight bleeding from the epiglottic vallecula occurred at the puncture site, which also stopped spontaneously within 10 min in all cases. Erroneous puncture of the cricothyroid membrane occurred in three patients (0.5 %), and the puncture step had to be repeated in 38 patients (6.7 %) because the initial site was not optimal. There were no serious complications. The planned surgical procedure was completed in all (100 %) of the patients who underwent surgery. Fig. 5 Incision of a large vocal fold cyst
Discussion
Fig. 6 Incision of the surface of a vocal fold nodule
Surgical results Cases From January 2011 through December 2013, we used the DBCN to perform day surgeries on 566 patients at our facility. Topical anesthesia was given and the patients were in a state of wakefulness during the surgeries. Operations were performed for vocal fold polyps in 34 cases (6 %), vocal fold nodules in 21 cases (4 %), vocal fold cysts in 24 cases (4 %), spasmodic dysphonia in 412 cases (73 %),
123
While laryngomicrosurgery under general anesthesia is the most common surgical method for treating vocal fold lesions, such as polyps and nodules, day surgery using local anesthesia has also been tried, with surgical results similar to those with laryngomicrosurgery under general anesthesia. Laryngomicrosurgery under general anesthesia requires hospitalization of the patient and is burdensome to the patient in terms of cost and hospitalization time. General anesthesia itself is associated with the risk of complications, besides which the surgery can be difficult in elderly patients with decreased cardiopulmonary function or a history of disease of other vital organs. On the other hand, day surgery for vocal fold lesions performed using topical anesthesia does not require hospitalization, reducing the burdens of surgical cost and treatment time on the patient. Resection of vocal fold lesions under topical anesthesia on an outpatient basis is usually performed by peroral excision using special forceps while observing the glottis by laryngeal fiberscopy [8]. However, this method can readily induce the gag reflex and cause pain, such that the surgery is difficult to complete in patients who react strongly; completion is impossible in about 10 % of patients. With the method we have reported here, no tools have to be inserted perorally, making interruption of the procedure due to stimulation of the gag reflex rare. None of the 566 operations we performed on patients from 2011 to 2013 had to be abandoned due to activation of the gag reflex. Similarly, vocal fold injection procedures have been attempted in patients in the awake state and using topical anesthesia, by a method in which the injection materials were injected into the vocal folds perorally using a laryngeal injection needle [2]. However, the gag reflex sometimes interferes with this procedure, as well. Further,
Eur Arch Otorhinolaryngol (2014) 271:3095–3099
about 0.5 mL of injection material remains in the laryngeal injection needle and is, thus, wasted. In cases in which an expensive injection material, such as hyaluronic acid or hydroxyapatite, is used, the financial burden on the medical facility, and thus, the patient, increases. Moreover, the size of a laryngeal injection needle is 19G, as a result of which the injected material readily leaks out of the puncture site. In our method, we use a 23G needle, and although leakage occurs with this needle as well, the amount is less since the puncture site is smaller due to the narrow gauge of the needle. Vocal fold injection performed by THA under topical anesthesia was first reported by Amin in 2006 [4]. However, the injection needle, used in Amin’s method, was an ordinary straight needle, so it could not be inserted into some target sites depending on the angle [5, 6]. Achkar et al. [7] tested vocal fold injection using a 38-mm, 25G needle that was bent 45° at its base and also 45° at 1 cm from its tip. However, in Achkar’s method, as well, the needle was not long enough, meaning that the tip of the needle could not reach the target site in patients with a large larynx. On the other hand, our method DBCN use long needle which is enough to reach any size larynx. So we can reach all sites of the vocal folds bilaterally, including anteriorly, posteriorly and laterally, enabling surgical manipulations at all target sites.
Conclusions The DBCN reported here for treatment of vocal fold lesions can be performed on an outpatient, day-surgery basis, and as a result, it reduces the physical and financial burden on patients. Also, the DBCN avoids triggering the gag reflex, which is an issue in patients undergoing
3099
laryngeal surgery using conventional methods. Moreover, vocal fold injection can be accomplished using a lesser volume of expensive injection materials compared with conventional injection. This latter point is advantageous in that it reduces the financial strain on medical facilities. Acknowledgments No funding or grants were received for this work. This method is approved in an Ethical Review Board of Tokyo Medical University.
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