Inpatient Type 1 Thyroplasty Versus Injection Laryngoplasty for Vocal Fold Movement Impairment After Extent type I and II Aortic Repair

Abstract

Importance:

Vocal fold motion impairment (VFMI) due to neuronal injury is a known complication following thoracic aortic repair that can impair pulmonary toilet function and post-operative recovery.

Objective:

To demonstrate clinical outcomes of patients undergoing inpatient vocal fold medialization for VFMI after aortic surgery.

Design:

A 15-year retrospective chart review (2005-2019) of 259 patients with postoperative VFMI after thoracic aortic surgery registry was conducted. Data included demographics, surgery characteristics, laryngology exam, and postoperative clinical outcomes. Medialization procedures consisted of type 1 thyroplasty and injection laryngoplasty.

Setting:

Tertiary care hospital

Participants:

Two hundred and fifty-nine patients (median age 61, 71% male) with VFMI post-thoracic aortic repair met inclusion criteria; inpatient vocal fold medialization was performed for 203 (78%) patients. One hundred and twenty-six. (49%) received type 1 thyroplasty and 77 (30%) received injection laryngoplasty procedures at a median 7 days (IQR 5-8 days) from extubation.

Main Outcomes:

Primary study outcome measurements consisted of median LOS, median ICU LOS, complications intra- and postoperatively, and pulmonary complications (post-medialization bronchoscopies, pneumonia, tracheostomy, etc.).

Results:

Post-medialization bronchoscopy rates were significantly lower in the medialization (n = 11) versus the non-medialization group (n = 8) (5% vs 14%, P = .02) and significantly higher in the injection laryngoplasty group (n = 77) versus thyroplasty group (n = 126) (10% vs 2%, P = .02). Further analysis revealed no significant difference in overall LOS and pulmonary complications between the techniques.

Conclusion:

Inpatient thyroplasty and injection laryngoplasty are both effective vocal fold medialization techniques after extent I and II aortic repair. Thyroplasty may have a small pulmonary toilet advantage, as measured by need for post-medialization bronchoscopy, compared to injection laryngoplasty.

Keywords

vocal fold paralysis vocal fold medialization injection laryngoplasty type 1 thyroplasty pulmonary complications

Introduction

Because of its circuitous route through the neck and chest, the recurrent laryngeal nerve (RLN) is at risk for compression, stretch, thermal injury, or transection during intrathoracic aortic aneurysm or dissection repair. The rate of vocal fold motion impairment (VFMI) after aortic surgery is 9% to 32%.^1-4 VFMI may result in a breathy or weak voice, ineffectual cough and decreased airway clearance ability, resulting in aspiration, respiratory insufficiency, and swallowing difficulties.⁵ Patients with VFMI have been reported to have higher rates of therapeutic bronchoscopies, pneumonia, and longer hospital and ICU length of stay during the postoperative period.^2,6 To address the increased pulmonary burden, inpatient vocal fold medialization via type 1 thyroplasty or injection laryngoplasty, may facilitate glottic closure to bolster airway protection and reduce aspiration risk.^1,7,8

With pulmonary complications being a prevalent adverse outcome following open aortic repair, optimizing pulmonary toilet function remains critical to recovery.⁹ Prior studies of vocal fold medialization in the postoperative period have demonstrated it as safe and feasible with several studies reporting decreased need for therapeutic bronchoscopies.^8,10
-12 However, investigations on inpatient vocal fold medialization techniques after thoracic aortic surgery have remained limited and primarily in small-size case series. Recent publications from our institution have reported shorter length of stay after thoracic aortic surgeries with inpatient vocal fold medialization and with early injection laryngoplasty.^12,13 The purpose of this study is to determine if there is any difference in pulmonary outcomes and complications between inpatient vocal fold medialization with type 1 thyroplasty versus injection laryngoplasty in patients who underwent thoracic aortic repair.

Materials and Methods

With Institutional Review Board approval, a prospectively collected institutional database of aortic surgery patients was used to identify patients with unilateral VFMI following extent type I and II aortic aneurysm or dissection repair performed from 2005 through 2019 at a single tertiary care academic institution. A total of 259 patients with VFMI were identified and their medical records were reviewed.

Variables include demographics, surgery characteristics, presenting symptoms, laryngology evaluation, postoperative complications, need for tracheostomy, and mortality. Hospital length of stay (LOS) was defined as duration of inpatient stay prior to discharge or transfer to another facility or rehabilitation service. Patients were screened for vocal fold evaluation based on acoustic features (ie, loudness during phonation, weak cough, dysphonia) and underwent bedside flexible nasolaryngoscopy (FNL) to assess for VFMI. Patients with vocal fold paresis, or hypomobility but not complete paralysis, were excluded from the study. Due to a shift in techniques, type 1 thyroplasty was predominantly performed in early data collection while injection laryngoplasty was predominantly performed after 2014. Reasons patients did not undergo inpatient medialization included patient refusal, preference for outpatient setting closer to home, and further adverse events precluding the procedure. Type 1 thyroplasty was performed in the operating room under sedation and local anesthesia with silastic implants (Implantech, Ventura, CA) via either an Isshiki or Netterville style approach.^14
-16 Injection laryngoplasty was performed via a thyrohyoid approach under local anesthesia with methylcarboxycellulose (Prolaryn Voice Gel, Raleigh, NC) or Cymetra, as previously described by Chen et al.¹²

Primary endpoint was pulmonary toilet-related complications, and secondary endpoint was hospital LOS. Pulmonary toilet-related complications consisted of post-medialization pneumonia, therapeutic bronchoscopy, reintubation, and tracheostomy. For time-to-medialization, the date of last extubation prior to intervention was used.

Categorical variables were analyzed with chi-square and exact Fisher’s tests. Means of continuous values were compared using a two-tailed student t-test. A one-way between-subjects ANOVA was conducted to compare the effects of medialization technique on variables found to have significant differences in prior analyses. Comparisons were made between type 1 thyroplasty, early injection laryngoplasty, and late injection laryngoplasty. Games-Howell post hoc comparisons were conducted for variables that proved to be statistically significant on analysis of variance. Significance was determined with a confidence interval of 95% and P < .05 for all statistical tests.

Results

There were 259 patients with postoperative VFMI who met inclusion criteria for this study. Inpatient vocal fold medialization was performed for 203 (78%) patients with 126 (49%) type 1 thyroplasty and 77 (30%) injection laryngoplasty procedures. Table 1 exhibits the demographic characteristics of patients with and without medialization. There were no major differences in age, gender, ethnicity, medical comorbidities, or aortic pathology. The median time of medialization from last extubation was 7 days (IQR 5-8 days). About 20% of medializations occurred while patients were in the intensive care unit.

Table 1.

Characteristics of Patients With Postoperative Vocal Fold Motion Impairment (VFMI) Following Aortic Surgery Who Did or Did Not Undergo Vocal Fold Medialization (VFM).

Characteristic	VFMI	VFM	Non- VFM	P value
Characteristic	n (%)	n (%)	n (%)	P value
No. patients	259	203 (78)	56 (22)
Median age (IQR, years)	61 (49-70)	61 (49-69)	60 (48-70)	.63
Male gender	185 (71)	149 (73)	36 (65)	.33
Ethnicity
Caucasian	178 (69)	139 (68)	39 (70)	.86
Black or African-American	34 (13)	23 (11)	11 (20)	.10
Hispanic or Latino	32 (12)	27 (13)	5 (9)	.38
Asian or Pacific Islander	10 (4)	10 (5)	0 (0)	.12
Other	5 (2)	4 (2)	1 (2)	1.00
Smoking history
Never smoker	112 (36)	94 (46)	18 (32)	.06
Current or former smoker	144 (56)	107 (54)	37 (6)	.08
Unknown	3 (1)	2 (1)	1 (2)	1.00
Diabetes mellitus	20 (8)	18 (9)	2 (4)	.26
Underlying genetic disorder	66 (25)	53 (26)	13 (23)	.66
Aortic pathology
Aneurysm without dissection	61 (24)	48 (24)	13 (23)	1.00
Aortic dissection	198 (76)	155 (76)	43 (77)	.57
Acuity of dissection
Acute	17 (7)	14 (7)	3 (5)	.77
Subacute	7 (3)	3 (1)	4 (7)	.04*
Chronic	174 (67)	138 (68)	36 (64)	.60
Previous aortic operation	14 (5)
Postoperative VFP
Left	251 (97)	200 (99)	51 (91)	.01*
Bilateral	8 (3)	3 (1)	5 (9)	<.01*
Vocal fold medialization	—	203 (100)	—
Type 1 thyroplasty	—	126 (62)	—
Injection laryngoplasty	—	77 (38)	—
Median length of intubation (days, IQR)	2 (1-4)	1 (1-4)	2 (1-4)	.86
Medialization in ICU	—	40 (20)	—
Median surgery-to-medialization time (days, IQR)	—	8 (7-11)	—
Median extubation-to-medialization time (days, IQR)	—	7 (5-8)	—

Abbreviation: IQR, interquartile range.

Statistically significant defined as P < .05.

Two patients (1%) had complications following medialization, and both were after type 1 thyroplasty. One of these patients experienced bleeding and developed a hematoma at the surgical site, requiring reoperation. The other patient aspirated after the procedure and required intubation, subsequent bronchoscopy, and ultimately, tracheostomy.

In patients who underwent medialization, pulmonary toilet-related complications affected 61 (30%) patients (Table 2). The most prevalent complication was post-medialization pneumonia (28 patients, 14%) followed by reintubation (25 patients, 12%), tracheostomy (23 patients, 11%), and therapeutic bronchoscopy (11 patients, 5%). Comparatively, for the 56 patients without medialization, 20 (36%) patients had pulmonary toilet-related complications, consisting of reintubation (10 patients, 18%), tracheostomy (9 patients, 16%), bronchoscopy (8 patients, 14%), and pneumonia (3 patients, 5%). While there was no statistical difference in rate of total pulmonary toilet-related complications between medialization and non-medialization cohorts, the rate of therapeutic bronchoscopies was significantly less in the medialization group than the non-medialization group (5% vs 14%, P = .02). There was no significant difference in median hospital LOS between the two groups (15 vs 12 days, P = .30).

Table 2.

Pulmonary Toilet-Related Complications in VFMI Patients With and Without Vocal Fold Medialization (VFM) Following Thoracic Aortic Surgery.

Characteristic (%)	VFM	Non-VFM	P value
Characteristic (%)	n = 203	n = 56	P value
No. Patients with complication	61 (30)	20 (36)	.52
Therapeutic bronchoscopy	11 (5)	8 (14)	.02*
Pneumonia	28 (14)	3 (5)	.10
Reintubation	25 (12)	10 (18)	.38
Tracheostomy	23 (11)	9 (16)	.36
Median ICU LOS (days, IQR)	6 (4-11)	5 (4-11)	.70
Median hospital LOS (days, IQR)	15 (10-22)	12 (9-20)	.30

Abbreviations: IQR, interquartile range; VFMI, vocal fold motion impairment.

Statistically significant defined as P < .05.

Comparison of medialization techniques with injection laryngoplasty and type 1 thyroplasty are reported in Table 3. Median time-to-medialization from extubation did not significantly differ between the thyroplasty and the injection laryngoplasty group (7 vs 5 days, P = .14). Total pulmonary toilet-related complications (29% vs 31%, P = .64) and LOS (14 vs 16 days, P = .20) also did not differ. However, post-medialization bronchoscopy rates were significantly higher in the injection laryngoplasty than in the thyroplasty group (10% vs 2%, P = .02). Postprocedural duration of intubation was also significantly greater in the injection versus the thyroplasty group (2 vs 1 days, respectively, P = .04). ANOVA analysis revealed incidence of post-medialization bronchoscopy significantly related to type of medialization technique (P = .039) but not to duration of intubation (P = .144). Post hoc testing indicated rate of post-medialization bronchoscopy was marginally lower for patients who received thyroplasty (P = .061) compared to late injection laryngoplasty. There was no statistically significant difference between early injection (P = .219) and thyroplasty or between any other paired techniques.

Table 3.

Thyroplasty Versus Injection Laryngoplasty VFM for Patients With VFMI After Thoracic Aortic Surgery.

Characteristic (%)	Thyroplasty	Injection	P value
Characteristic (%)	n = 126	n = 77	P value
Time from surgery to VFM (days, IQR)	8 (8-14)	7 (5-10)	.12
Time from extubation to VFM (days, IQR)	7 (6-8)	5 (3.5-6)	.14
ICU LOS (days, IQR)	6 (3-10)	6 (4-11)	.45
Hospital LOS (days, IQR)	14 (10-21)	16 (12-24)	.20
Duration of intubation (days, IQR)	1 (1-4)	2 (2-5)	.04*
Incidence of pulmonary toilet-related complications	36 (29)	25 (31)	.64
Pneumonia	17 (13)	11 (14)	1.00
Bronchoscopy	3 (2)	8 (10)	.02*
Re-intubation	17 (13)	8 (10)	.66
Tracheostomy	14 (11)	9 (12)	1.00

Abbreviations: IQR, interquartile range; VFMI, vocal fold motion impairment.

Statistically significant defined as P < .05.

Discussion

Postoperative VFMI following aortic arch surgery from recurrent laryngeal nerve injury is reported to affect 9% to 32% of patients.^1
-3 As described by Ohta et al² and DiLisio et al,⁶ VFMI presents a risk for poorer pulmonary outcomes.^1,3 For VFMI patients, weak cough and poor airway secretion clearance increase the risk of aspiration, pneumonia, reintubations, tracheostomy, length of stay and readmission to intensive care for respiratory failure demonstrated in affected patients after intrathoracic surgery.^2,6,17
-19

Barbu et al⁷ reported outcomes on postoperative bedside injection medialization to facilitate recovery in the postsurgical period. Inpatient type 1 thyroplasty can improve symptoms of hoarseness, dyspnea, and dysphagia for patients with transected RLN during pulmonary resections for lung cancer.^20,21 In our earlier case series, patients who underwent vocal fold medialization after total arch surgery had shorter ICU and hospital LOS than those who did not undergo medialization.¹³ We have previously demonstrated anticoagulation therapy can be safely continued for awake transcervical injection, facilitating earlier medialization, and earlier injection laryngoplasty has been associated with shorter LOS in our patient population.^12,22

Our current results present a cohort of patients with VFMI undergoing inpatient type 1 thyroplasty versus injection laryngoplasty following extent I and II thoracic aortic repair. In a comparison of medialization techniques, type 1 thyroplasty had significantly fewer post-medialization bronchoscopies than injection laryngoplasty (Table 3). We found that decrease in bronchoscopy rate neared significance in the thyroplasty group compared to late injection but did not differ greatly from early injection. Possible reasons for this difference include a more robust implant with thyroplasty and less chance of extrusion. Compared to voice gel injection media, the firmer material used in thyroplasty is at lower risk for early extrusion and may better allow the arytenoids to rotate posteriorly, lending a stronger cough.

Technique preference and implant material are often variable amongst surgeons as both techniques have inherent advantages and disadvantages such as, technical difficulty and patient tolerance to a lengthier operation. Our institutional practice of medialization shifted from type 1 thyroplasty to injection laryngoplasty in 2014 due to surgeon preference. Injection laryngoplasty carried a low complication rate (<1%), is safe with ongoing anticoagulation, is faster to perform, and thus is more favorable as a temporary measure.

Whereas prior studies demonstrated longer LOS in non-medialized and later-timed medializations,^12,13 LOS measures did not differ in this study. The total pulmonary complications rates were comparable between medialization and non-medialization patients; however, since medialization was not randomized, there may be selection bias in which patients with better pulmonary strength were not selected for medialization.

The rate of total pulmonary-toilet complications for the entire cohort (30%) was slightly lower than prior large series investigations of aortic aneurysm repairs in which pulmonary complications occurred in 45% to 48% of patients.^23,24 This lower rate of pulmonary complications may reflect our pulmonary-toilet related focus and exclusion of other pulmonary complications such as pneumothorax, pleural effusion, prolonged duration of intubation, and chylothorax.

Strengths of this work include an overall large sample size relative to other studies in a targeted surgical population and comparison of cohorts with and without medialization and related techniques. Limitations involve small sample sizes among the medialization subgroups (ie, early injection, late injection) and retrospective design.

Conclusion

Vocal fold medialization, via inpatient thyroplasty or injection laryngoplasty, can help improve pulmonary toilet function after extent I and II aortic repair. Patients undergoing inpatient type 1 thyroplasty required significantly fewer post-medialization bronchoscopies compared to those who received injection laryngoplasty, but further analyses indicated no significant difference in pulmonary toilet complications among different medialization techniques. In the future, larger sample sizes may help clarify whether controlling for the timing of medialization affects these results.

Footnotes

Authors’ Note

Presented at Combined Otolaryngology Spring Meetings Online Poster Presentation 2020 Virtual Poster Session (May 15-June 15, 2020).

Contributions

(I) Substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data: All authors (II) Drafting the article or revising it critically for important intellectual content: All authors, (III) Final approval of the version to be published: All authors, (IV) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: All authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Lauren A. Pinzas

Julina Ongkasuwan

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