Transcricothyroid Membrane Vocal Fold Injection
The purpose of this procedure is to deliver augmentation material or therapeutic substances to the vocal folds. Office-based injection laryngoplasty allows for precise delivery through the cricothyroid membrane in conjunction with excellent fiberoptic visualization from the supraglottis. It provides real-time feedback and mucosal wave analysis (when stroboscopy is used) for excellent results.
Indications/Contraindications
Common indications for vocal fold augmentation include glottic insufficiency from vocal fold paralysis/paresis, atrophy, scar, cancer defects or trauma.
Common indications for delivery of bioactive agents, such as Botox A or steroids, include spasmodic dysphonia and laryngeal tremor as well as Reinke′s edema, respectively.
This approach is ideal for patients who are unable or unwilling to undergo OR-based injection laryngoplasty (medical contraindications to general anesthesia, difficult laryngeal exposure, patient preference).
Patient intolerance or unwillingess to undergo an awake procedure are relative contraindications. However, the procedure is extremely safe, even in those on blood thinners, such as Coumadin, aspirin, or Plavix.
In the Clinical Setting
Key Points
It is important to work with the patient to anesthetize appropriately and to minimize any swallowing, coughing, or discomfort, in order to allow for precise placement of injectate.
Pitfalls
This procedure requires local anesthetic with the patient awake and aware. The patient must be anesthetized appropriately to provide comfort. If there is not enough anesthetic, the patient may feel uncomfortable and not tolerate the procedure. If there is too much anesthetic, the patient may pool secretions, have significant globus sensation, or swallow excessively. With any injection laryngoplasty (especially bilateral), there is a risk of airway compromise.
From a Technical Perspective
Key Points
This procedure can be performed successfully with transnasal fiberoptic guidance (more often for augmentation when avoidance of the lamina propria is essential) or without fiberoptic guidance, as is often performed with Botox.
Familiarity with details such as the “pop” sensation when traversing the cricothyroid membrane and three-dimensional knowledge of the site of the needle tip can be vastly improved by practice in the laboratory.
Pitfalls
Injection of augmentation materials into the lamina propria rather than the vocal fold musculature is to be avoided as it will almost certainly deleteriously affect voice quality rather than improve it. This is a well-recognized complication and should be assiduously avoided.
Excess motion of the tip of the needle can tear vocal fold epithelium and induce unnecessary trauma, so smooth “in and out” motions are preferred to “back and forth” motions.
With augmentation materials, wiping the needle tip clean prior to inserting will prevent undesired deposition of material superficially in the vocal fold.
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